ion  Compends 


Essentials  of 

Medical  Diagnosis 


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FRONTISPIKCE 


CEO   S  HARRIS  »SONS,LITH  P»'i-i 


THE  RELATIONS  OF  THE  THORACIC  AND 
ABDOMINAL  VISCERA, 

THE  ANTERIOE  THORACIC  AND  ABDOMINAL  WALLS  REMOVED. 

A. — Upper  bone  of  the  sterDum. 

B.B.*— Two  first  ribs. 

C.C.* — Second  pair  of  ribs. 

D.D.* — Right  and  left  kings. 

E. — Pericardium,  enveloping  the  heart — the  right  ventricle. 

F. — Lower  extremity  of  tlie  sternum. 

G.G.* — Lobes  of  the  liver. 

H.H.* — Right  and  left  halves  of  the  diaphragm,  in  section  ;  the 
right  half  separating  the  right  lung  from  the  liver, 
the  left  half  separating  the  left  lung  from  the  cardiac 
extremity  of  the  stomach. 

I.I.* — Eighth  pair  of  ribs. 

K.K.*— Kinth  pair  of  x'ibs. 

L.L.^ — Tenth  pair  of  ribs. 

M.M.* — The  stomach. 

N. — The  umbilicus. 

O.O.* — The  transverse  colon. 

P.P.* — The  omentum,  covering  the  transverse  colon  and  small 

intestines. 
Q.— The  gall-bladder. 

R.R.* — The  right  and  left  pectoral  prominences. 
S.S.* — The  small  intestines. 


Since  the  issue  of  the  first  volume  of  the 
Saunders  Question=Compends, 

OVER  175,000  COPIES 

of  these  unrivalled  publications  have  been  sold. 
This  enormous  sale  is  indisputable  evidence 
of  the  value  of  these  self-helps  to  students 
and  physicians. 


Saunders'  Question  Compends,  No*  17, 

ESSENTIALS  OF  DIAGNOSIS 

ARRANGED    IN    THE    FORM    OF 

QUESTIONS  AND  ANSWERS 

PREPARED    ESPECIALLY    FOR 

STUDENTS  OF  MEDICINE. 

BY 

SOLOMON   SOLIS-COHEN,  M.  D, 

Professor  of  Clinical  Medicine  and  Therapeutics  in  the  Philadelphia 
Polyclinic;   Lecturer  on  Clinical  Medicine  in  Jefferson  Medical 
College;  Physician  to  the  Philadelphia  Hospital  and  to 
the  Rush  Hospitcd  for  Consumptives,  etc., 

AND 

AUGUSTUS   A.  ESHNER,  M.  D., 

Professor  of  Clinical  Medicine  in  the  Philadelphia  Polyclinic; 
Physician  to  the  Philadelphia  Hospital,  etc. 

ILLUSTRATED. 

SECOND   EDITION,  REVISED  AND   ENLARGED. 


PHILADELPHIA  : 

W.  B.  SAUNDERS; 

925  Walnut  Street. 
1900. 


GIFT 

Copyright,  1900. 
By  W.   B.    SAUNDE 


TO 


J.  M.  Da  COSTA,  M.D.,  LL.D., 

EMERITUS  PROFESSOR  OF  THE  PRACTICE  OF  MEDICINE  AND  OF  CLINICAL  MEDICINE 
IN  JEFFERSON  3IEDICAL  COLLEGE, 


THE    MASTER   DIAGNOSTICIAN, 
THE    BRILLIANT    TEACHER,  THE   DISTINGUISHED   CLINICIAN, 

THIS  LITTLE   BOOK 
IS    AFFECTIONATELY    INSCRIBED 

BY 

TWO  GRATEFUL  PUPILS. 


PREFACE  TO  THE  SECOND  EDITION. 


This  book  lias  been  thoroughly  revised  and  considerably 
enlarged.  Much  new  material  has  been  added,  and  recent 
additions  to  knowledge  incorporated.  Designed  primarily 
for  students,  no  attempt  has  been  made  to  render  the  work 
encyclopedic,  yet  it  is  believed  that  the  essentials  of  the  sub- 
ject have  been  set  forth  with  sufficient  fulness  to  serve  even 
for  reference  by  the  practising  physician.  The  book  is  not  a 
mere  compilation,  but,  while  based  upon  the  common  knowl- 
edge and  its  records,  represents  in  no  small  measure  the 
results  of  personal  observation.  Care  has  been  taken  to  omit 
mere  opinions,  and,  as  before,  it  has  been  deemed  wisest  in 
matters  of  doubt  to  set  forth  most  prominently  the  prevailing 
view.  The  kind  words  of  correspondents,  the  cordial  reception 
accorded  the  first  edition  by  the  medical  j^ress  of  England 
and  America,  and  the  comparatively  large  sale  of  the  book 
in  Great  Britain  and  the  British  colonies,  have  been  to  us 
sources  of  pleasure,  for  which  we  herewith  make  grateful 
acknowledgment. 

s.  s.  c. 

A.  A.  E. 
5 


PREFACE. 


This  book  is  intended  to  meet  a  popular  demand.  While 
the  endeavor  has  been  to  make  it  reliable  and  helpful,  the 
student  is  advised  not  to  depend  upon  it  to  the  exclusion  of 
standard  and  more  elaborate  works.  It  is  elementary  in 
character,  devoid  of  detail,  and  represents  but  an  outline  of 
the  subject  with  which  it  has  to  deal.  This  outline  must  be 
filled  from  observation  and  further  reading. 

Being  written  especially  for  students,  everything  has  been 
sacrificed  to  accuracy  and  brevity ;  references  to  authori- 
ties consulted  have  been  omitted ;  and  it  has  been  deemed 
wisest  to  conform  with  prevailing  views  in  matters  concern- 
ing which  there  may  be  differences  of  professional  opinion. 

In  the  arrangement  of  material,  systematic  classification 
has  often  been  departed  from,  to  secure  the  benefit  of  associa- 
tion of  ideas. 

Diagnosis  must  be  studied  from  patients,  not  from  books ; 
even  the  best  of  books  can  only  direct  the  student  what  to 
look  for  at  the  bedside,  and  warn  him  against  probable 
errors. 

If  this  book  facilitates  the  true  methods  of  study,  it  will 
have  accomplished  its  purpose. 

6 


CONTENTS. 


PAGE 

The  Principles  and  Methods  of  Diagnosis 17 

Fever        27 

Simple  Continued  Fever— Ephemeral  Fever— Febricula 31 

Ardent  Fever 31 

Catarrhal  Fever— Influenza— Epidemic  Catarrh— La  Grippe 32 

Typhoid  Fever — Enteric  Fever 35 

Typhus  Fever 4^ 

Cerebro-spinal  Fever— Epidemic  Cerebro-spinal  Meningitis 46 

Asiatic  Cholera— Cholera  Infectiosa 50 

Eelapsing  Fever 52 

Malarial  Diseases 54 

Malta  Fever • q^ 

Bubonic  Plague     g2 

Beriberi go 

Yellow  Fever g^ 

Weil's  Disease g7 

Leprosy gg 

The  Exanthemata go 

Morbilli— Measles— Eubeola 69 

Scarlatina — Scarlet  Fever 70 

Eubella—Eothelu—Eoseola— German  Measles— French  Measles    .   74 

Variola— Smallpox 75 

Varicella— Chickenpox 79 

Erysipelas 80 

Glandular  Fever 82 

^Miliaria— Miliary  Fever— Sweating  Disease      82 

Dengue— Break-bone  Fever 83 

Diphtheria 84 

Glanders — Farcy — Equinia .87 

Anthrax— Wool-sorters'    Disease  —  Charbon- Malignant       Pustule- 
Splenic  Fever 89 

Actinomycosis 9q 

r 


O  COXTEXTS. 

PAGE 

Foot-and-mouth  Disease 91 

Milk-sickness 91 

Hydatid  (Echinococcus)  Disease 92 

Trichiuiasis 93 

Filariasis 95 

Dracontiasis 95 

Acute  Klieumatisni — Rheumatic  Fever .  95 

Gonorrheal  Synovitis 97 

Syphilitic  Arthritis 97 

Subacute  Rheumatism 98 

Myalgia      ' 98 

Chronic  Rheumatism     .    .    .    .  • 99 

Acute  Gout 99 

Chronic  Gout 101 

Lithemia 101 

Rheumatoid  Arthritis — Arthritis  Deformans 102 

The  Blood 104 

Anemia 106 

Chlorosis 107 

Pernicious  Anemia •       •    •  107 

Hyperleukocytosis  (Leukocytosis) 108 

Leukemia • 109 

Pseudo-leukemia — Hodgkin's  Disease — Lymphatic  Anemia— Ma- 
lignant Lymjihoma  or  Lymphadenoma Ill 

Infantile  Pseudo-leukemic  Anemia 112 

Scorbutus — Scurvy 113 

Purpura H'^ 

Hemophilia H^ 

Addison's  Disease H^ 

Rachitis      ^"^ 

Mollities  Ossium      H^ 

The  Heart H^ 

Inspection      • H^ 

Palpation H^ 

Percussion     .    .    .  • H^ 

Auscultation 120 

Malformation 1~0 

Dextrocardia •  1~"^ 

Functional  Disturbance  of  the  Heart 125 

Tachycardia      ^"~6 

Brachycardia I"'-' 

Irritable  Heart •  ^27 


CONTENTS.  y 

PAGE 

Angina  Pectoris 128 

Hypertrophy  of  the  Heart 128 

Dilatation  of  the  Heart 129 

Valvular  Disease  of  the  Heart 131 

Mitral  Incompetency— Mitral  Regurgitation      132 

Mitral  Obstruction      132 

Aortic  Obstruction 133 

Aortic  Incompetency— Aortic  Regurgitation 133 

Tricuspid  Incompetency — Tricuspid  Regurgitation      134 

Tricuspid  Obstruction 135 

Pulmonary  Obstruction 135 

Pulmonary  Incompetency — Pulmonary  Regurgitation 135 

Acute  Pericarditis 135 

Diseases  of  the  Myocardium 138 

Acute  Endocarditis 139 

Heart-clot      140 

Diseases  of  the  Mediastinum 141 

Thoracic  Aneurism 141 

Arterio-capillary  Fibrosis 143 

Local  Syncope— Local  Asphyxia— Local  or  Symmetrical  Gangrene  .  144 

Erythromelalgia      ^^^ 

Angioneurotic  Edema 146 

The  Respiratory  System 146 

Coryza— Acute  Xasal  Catarrh      148 

Hay-fever— Hay-asthma— Rag-weed  Fever  -Autumnal  Catarrh— 
June-cold— Rose-cold— Idiosyncratic  Coryza— Periodic  Vasomo- 
tor Corvza     ^^^ 

1  nO 

Acute  Larvngitis 

1  ^1 
Edema  of  the  Larynx -^^^ 

Acute  Tuberculous  Laryngitis l-"^'- 

Larvngismus  Stridulus , ■^"''^ 

Laryngeal  Vertigo      _ 

Catarrhal  Croup- Spasmodic  Croup l'^4 

Membranous  Croup l^^ 

Whooping-cough— Pertussis 1^' 

Chronic  Laryngitis 1^^ 

Chronic  Tuberculosis  of  the  Larynx '^^^ 

159 
Physical  Diagnosis ]_ 

Acute  Pleurisy • ^ 

169 
Chronic  Pleurisy 

Acute  Bronchitis ^ 

Chronic  Bronchitis .   1/1 


10  CONTENTS. 

PAOE 

Plastic  Bronchitis — Fibrinous  Bronchitis 172 

Putrid  Bronchitis 172 

Bronchiectasis 173 

Capillary  Bronchitis 174 

Catarrhal  Pneumonia — Broncho-pneumonia — ^Lobular  Pneumo- 
nia           175 

Acute  Croupous  Pneumonia — Lobar  Pneumonia 176 

Pulmonary  Gangrene 182 

Pulmonary  Tuberculosis 182 

Acute  Miliary  Tuberculosis 191 

Interstitial  Pneumonitis 193 

Pulmonary  Emphysema 194 

Pneumothorax 195 

Asthma 197 

New-growths  in  the  Lungs 199 

The  Digestive  System— The  Mouth 199 

Catarrhal  Stomatitis 199 

Aphthous  Stomatitis 200 

Thrush — Muguet — Parasitic  Stomatitis 200 

Ulcerative  Stomatitis 200 

Mercurial  Stomatitis 201 

Gangrenous  Stomatitis — Noma — Cancrum  Oris      . 201 

The  Tongue 202 

Glossitis 202 

Leukoplakia  Lingualis— Leukoplakia  Buccalis 202 

Geographical  Tongue 203 

Glossanthrax 203 

Mgrities — Black  Tongue — Hairy  Tongue .  203 

Mumps — Parotiditis 204 

The  Pharynx 204 

Pharyngitis =    c 204 

Tonsillitis 206 

Herpetic  Sore-throat — ^Herpetic  Tonsillitis — Herpes  of  the  Phar- 
ynx— Common  Membranous  Sore-throat — Ulcero-membranous 

Angina — Diphtheroid  Throat 208 

Gangrenous  Pharyngitis — Putrid  Sore-throat 209 

Eetro-pharyngeal  Abscess 210 

The  Esophagus 211 

Esophagitis 211 

Stricture  of  the  Esophagus 211 

The  Stomach 212 

Neuroses  of  the  Stomach 214 


CONTENTS.  11 

PAGE 

Splanchnoptosis 215 

Gastralgia      215 

Acute  Gastritis 215 

Clironic  Gastritis — Clironic  Gastric  Catarrli 217 

Dilatation  of  the  Stomach — Gastrectasis 218 

Gastric  Ulcer 218 

Carcinoma  of  the  Stomach 220 

The  Intestines 223 

Acute  Enteritis 223 

Memhranous  Enteritis 224 

Cholera  Morbus — Cholera  Nostras 225 

Cholera  Infantum 225 

Chronic  Enteritis — Chronic  Intestinal  Catarrh 225 

Acute  Dysentery 226 

Chronic  Dysentery 227 

Typhlitis— Appendicitis— Perityphlitis 228 

Intestinal  Obstruction 231 

Intussusception — Invagination 232 

Carcinoma  of  the  Intestine 233 

Intestinal  Parasites 234 

Tffinia  Solium 235 

Tfenia  Mediocanellata , 236 

Bothriocephalus  Latus 236 

Ascaris  Lumbricoides — Round- worms ,    .    .    .  237 

Ankylostomiasis 238 

Distomiasis 239 

Oxyuris     Vermicularis  —  Seat-worms  —  Thread-worms  —  Spool- 
worms     239 

Occlusion  of  the  Mesenteric  Vessels 240 

Acute  Peritonitis > 241 

Chronic  Peritonitis 243 

Tabes  Mesenterica 244 

The  Liver 244 

Floating  Liver 245 

Congestion  of  the  Liver 246 

Acute  Hepatitis 247 

Acute  Yellow  Atrophy  of  the  Liver 248 

Abscess  of  the  Liver 250 

Interstitial  Hepatitis — Cirrhosis  of  the  Liver 252 

Fatty  Liver 253 

Amyloid  Disease  of  the  Liver 254 

Carcinoma  of  the  Liver 254 


12  CONTENTS. 

PAGE 

Hydatid  Cyst  of  the  Liver 25G 

Perihepatitis : 258 

Cholangitis — Cholecystitis 258 

Biliary  Calculi 201 

The  Si)leen 263 

Floating  Spleen 264 

Splenitis 264 

Enlargement  of  the  Spleen — Splenic  Tumor 264 

Splenomegaly  (Banti's  Disease) 265 

The  Pancreas 265 

Acute  Pancreatitis 265 

Carcinoma  of  the  Pancreas 265 

Pancreatic  Cysts ' 266 

Pancreatic  Hemorrhage 266 

The  Genito-urinary  Apparatus 267 

Indicanuria 273 

Oxaluria 273 

Pyuria 274 

Albuminuria 275 

Chyluria 278 

Lipuria 279 

Hematuria 279 

Hemoglobinuria 280 

Paroxysmal  Hemoglobinuria 281 

Endemic  Hematuria 282 

Diabetes  Insipidus 282 

Glycosuria 283 

Diabetes  Mellitus 283 

Cystitis 288 

Vesical  Calculus 289 

Neoplasms  of  the  Bladder 289 

Pyelitis 289 

Eenal  Inadequacy 290 

Displacements  of  Kidney 290 

Eenal  Calculus 291 

Acute  Nephritis 292 

Chronic  Parenchymatous  Nephritis 292 

Amyloid  Kidney 293 

Chronic  Interstitial  Nephritis 293 

Abscess  of  the  Kidney •...-.    295 

Perirenal  Abscess 296 

Tuberculosis  of  the  Kidney 296 


CONTENTS.  13 

PAGE 

Malignant  Disease  of  the  Kidney 297 

Hydronephrosis '-'"'* 

Hydatid  Cyst  of  the  Kidney 298 

The  Nervous  System 299 

Neuritis " ^^~ 

Multiple' Neuritis ^^^ 

Sciatica ^^^ 

Facial  Hemiatrophy ^^^ 

Paralysis  of  the  Facial  Nerve 306 

Paralysis  of  the  Phrenic  Nerve 308 

Paralysis  of  the  Musculo-spiral  Nerve 309 

310 
Neuromata 

Neuralgia 310 

311 

Migraine 

Spinal  Meningitis ^-^"' 

Cervical  Pachymeningitis 313 

Hemorrhage  into  the  Spinal  Membranes 314 

Anemia  of  the  Spinal  Cord 314 

Hyperemia  of  the  Spinal  Cord 31o 

Myelitis      ^^^ 

Chronic  Myelitis 316 

Acute  Anterior  Poliomyelitis 318 

Acute  Ascending  Paralysis 319 

Amyotrophic  Lateral  Sclerosis— Progressive  Muscular  Atrophy— 

Glosso-labio-laryngeal  Palsy    .    , •   320 

Acute  Bulbar  Palsy 32o 

Pseudo-bulbar  Palsy  . 324 

Asthenic  Bulbar  Paralysis 324 

Progressive  Muscular  Dystrophy 324 

Arthritic  Muscular  Atrophy 326 

Thomsen's  Disease— Myotonia  Congenita    . 327 

Posterior  Spinal  Sclerosis— Locomotor  Ataxia— Tabes  Dorsalis    .   327 

Primary  Lateral  Sclerosis— Spastic  Paraplegia 329 

Postero-lateral  Sclerosis— Ataxic  Paraplegia 329 

Friedreich's  Ataxia— Hereditary  Ataxic  Paraplegia 331 

Cerebro-spinal  Sclerosis— Insular  Sclerosis— Multiple  Sclerosis- 
Disseminated  Sclerosis 332 

Paralysis  Agitans— Shaking  Palsy 333 

Spinal  Hemorrhage 33o 

Spinal  Compression 

Tumor  of  the  Spinal  Cord 337 


14  C  0  ^'  T  E  N  T  S  . 

PAGE 

Syringomyelia      339 

Morvau's  Disease — Analgesic  Panaris 340 

Cerebral  Meningitis 342 

Hydrocephalus 345 

Hemorrhage  into  the  Cerebral  Membranes 345 

Congenital  Spastic  Paraplegia 346 

Cerebral  Anemia 347 

Cerebral  Hyperemia 348 

Cerebritis 349 

Cerebral  Abscess 349 

Cerebral  Hemorrhage 350 

Cerebral  Softening ,,.... 354 

Cerebral  Embolism 355 

Cerebral  Thrombosis 356 

Cerebral  Tumor 357 

Intracranial  Aneurism 359 

General  Paralysis  of  the  Insane — Paretic  Dementia 359 

Sunstroke  —  Heat-stroke  —  Insolation  —  Heat-fever  —  Thermic 

Fever — Heat-exhaustion ^ 361 

Delirium  Tremens 363 

Plumbism 364 

Torticollis 366 

Occupation-neuroses 366 

Writers'  Cramp 367 

Chorea 368 

Hereditary  Chorea 369 

Spasmodic  Tic 369 

Epilepsy 370 

Hysteria 372 

Neurasthenia 375 

Family  Periodic  Paralysis 377 

Tetanus 377 

Tetany 379 

Hydrophobia 380 

Aural  Vertigo — Labyrinthine  Vertigo — Meniere's  Disease     .    .    -  381 

Exophthalmic  Goiter — Graves's  Disease — Basedow's  Disease    .    .  381 

Vasomotor  Ataxia 384 

Cretinism 384 

Myxedema 385 

Akromegaly 387 

Ehizomelic  Spondylosis 392 


ESSENTIALS 


OF 


MEDICAL  DIAGNOSIS. 


ESSENTIALS  OF  DIAGNOSIS. 


THE  PRINCIPLES  AND  METHODS  OF  DIAGNOSIS. 

Diagnosis,  in  mediciue,  is  the  art  and  science  of  observing 
and  of  discriminatingly  interpreting  the  phenomena  of  disease. 
In  its  study,  a  knowledge  of  the  phenomena  of  health  is  an 
essential  prerequisite.  Unless  familiar  with  the  sounds  elicited 
upon  percussion  of  the  normal  chest,  one  cannot  decide  whether 
or  not  the  sound  heard  in  a  given  case  is  indicative  of  abnormal 
conditions.  Unless  one  knows  the  characteristics  of  normal 
urine,  he  cannot  hope  to  gain  from  urinalysis  a  clue  as  to  the 
nature  of  a  case  of  disease.  Unless  one  knows  the  appearance 
of  a  healthy  brain,  he  cannot  determine  whether  the  brain  seen 
at  a  necropsy  is  or  is  not  the  seat  of  morbid  change.  Unless 
one  knows  the  function  of  a  normal  joint,  he  cannot  affirm  that 
a  joint  under  investigation  has  had  its  function  impaired. 

Having  learned,  by  observations  upon  the  healthy,  to  recog- 
nize when  departures  from  health  have  taken  place,  one  must 
further  learn  by  observation  of  the  sick  to  appreciate  the  sig- 
nificance of  such  departures.  1*^0  opportunity  should  be  lost  to 
examine  post  mortem  the  organs  and  tissues  that  have  been 
altered  by  disease. 

A  know^ledge  of  the  effects  of  drugs  upon  health)'-  and  un- 
healthy persons  and  organs  may  likewise  render  easy  a  diagr 
nosis  that  might  otherwise  be  difficult. 

The  phenomena  indicative  of  the  existence  of  disease  are  in  a 

general  wav-  termed  symjjtoms.     These  may  be  either  subjective — 

known  only  to  the  patient  b}-  his  sensations  ;   or  they  may  be 

o6Jecfw6— capable  of  investigation  by  the  senses  of  the  observer, 

-     2  (17) 


18  ESSENTIALS  OF  DIAGNOSIS. 

aided,  it  may  be,  by  instruments  of  precision.  Thus  pain,  ver- 
tigo, nausea,  ringing  in  tlie  ears,  are  subjective  symptoms,  while 
high  temperature,  vomiting,  unsteadiness  of  motion,  loss  of 
voice,  are  objective  symptoms. 

The  objective  manifestations  of  disease  may  be  further  divided 
into  symptoms  (in  a  restricted  sense)  and  signs.  While  the  two 
are  not  rigidly  separable,  symptoms  may  be  defined  as  manifesta- 
tions of  disordered  function,  signs  as  manifestations  of  altered 
structure.  Thus,  cough  is  a  symptom ;  the  laryngeal  congest- 
ion discovered  by  inspection  with  the  mirror,  the  bronchial 
rales  heard  upon  auscultation,  are  signs.  Difficulty  in  deglu- 
tition is  a  symptom  ;  a  pulsating  tumor  in  the  chest,  indicative 
of  aneurism  pressing  upon  the  esophagus,  is  a  sign.  Dyspnea 
is  a  symptom  ;  distension  of  the  abdomen  with  gas  (tympanites) 
or  with  fluid  (ascites),  causing  pressure  upon  the  diaphragm  and 
restricting  its  movements,  is  a  sign. 

Thus,  signs  are  in  many  cases  directly  explanatory  of  symp- 
toms, and  their  discovery  is  one  step  further  in  the  diagnosis. 
It  must  not  be  forgotten,  however,  that  signs  are  not  always  to 
be  found  ;  that,  when  found,  a  sign  may  not  account  in  toto  for 
the  symptom  with  which  it  is  associated  ;  and  that  even  when 
sufficient  to  explain  the  symptom,  the  sign  itself  remains  to  be 
explained  before  the  diagnosis  is  complete.  Like  all  other  mor- 
bid phenomena,  signs  must,  therefore,  be  considered  in  relation 
with  all  the  evidence  presented  in  a  given  case. 

Certain  signs  that  are  not  at  once  manifest,  but  that  require 
for  their  study  special  means  of  exploration,  are  termed  pliysical 
signs.  In  its  restricted  sense,  the  term  "physical  signs"  is 
applied  to  the  phenomena  elicited  by  special  methods  {ins2X'C- 
tion^  mensuration,  palpation,  pjercussion,  and  auscultation),  used 
chiefly  in  examination  of  the  chest  and  abdomen,  though  often 
applied  elsewhere  ;  while  the  signs  elicited  by  examination  of 
the  blood,  the  urine,  the  sputum,  the  feces,  or  by  laryngoscopy, 
ophthalmoscopy,  cystoscopy  and  the  like,  are  not  given  other 
qualifying  designation  than  the  special  names  describing  the 
respective  processes.  They  might  appropriately  be  termed 
instrumental  signs  and  signs  of  research. 

Phenomena  corresponding  Avith  logical  deductions  as  to  the 
direct  results  of  deranged  function,  including  subjective  and 


INTRODUCTION.  19 

objective  symptoms  and  signs,  are  called  rational  signs,  in  con- 
tradistinction from  physical  signs,  which  denote  the  mechanical 
condition  of  the  structures  examined.  Thus,  in  a  case  of  valvu- 
lar disease  of  the  heart,  weakness,  vertigo,  shortness  of  breath, 
pallor  and  dropsy  would  be  termed  rational  signs,  while  the 
area  of  cardiac  percussion-dulness  and  the  character  of  the 
sounds  heard  upon  auscultation  would  be  termed  physical  signs. 

Symptoms  may  also  he  divided  into  general  or  constitutional 
symptoms  and  local  symptoms.  General  symptoms  are  those, 
like  fever,  depression,  delirium,  that  may  result  from  unbalancing 
of  the  organism  as  a  whole,  and  are  common  to  afiections  of  many 
kinds  ;  while  local  symptoms  are  those,  like  swelling  or  discol- 
oration of  a  part  and  circumscribed  pain  or  tenderness,  that  are 
confined  to  a  certain  locality  and  result  from  localized  morbid 
conditions,  usually  that  of  the  organ  or  tissue  diseased. 

Symptoms  caused  by  local  disease  not  at  the  seat  of  mani- 
festation and  that  are  not  dependent  upon  mere  mechanical  in- 
fluences or  upon  interference  w^ith  related  function,  but  that 
arise  indirectly,  as  a  result  of  nervous  irritation,  are  termed 
reflex  symptoms.  Thus,  the  difficulty  of  breathing  occasioned  by 
the  pressure  of  a  mediastinal  tumor  upon  the  trachea  is  a  local 
symptom,  due  to  a  mere  mechanical  influence  ;  dys]mea  from 
deranged  action  of  the  heart  is  a  symptom  dependent  upon 
interference  with  related  function  ;  while  an  asthmatoid  condi- 
tion dependent  upon  disease  of  the  nose  is  a  reflex  symptom. 
It  must  not  be  forgotten,  however,  that  the  same  symptom 
may  at  one  time  be  local ;  at  another  time,  part  of  a  general 
process  ;  at  another  time,  reflex.  Thus,  vomiting  ma}^  indicate 
local  disease  of  the  stomach  ;  or  it  may  be  part  of  the  general 
disturbance  caused  by  certain  febrile  diseases  ;  or  it  may  re- 
flexly  indicate  disease  in  the  abdomen  or  in  the  brain. 

Having,  by  careful  observation  and  interrogation,  ascertained 
the  xwesent  condition  of  the  patient  and  having,  by  inquiry, 
learned  his  family  history  (in  order  to  judge  of  the  probable 
influence  of  hereditary  disease,  diathesis  or  liability)  and  his 
previous  history  (anamnesis)  of  health  or  disease  (including  a 
knowledge  of  his  mode  of  life  and  of  his  surroundings,  as  w^ell 
as  the  mode  of  invasion  of  the  disease  under  investigation  and 


20  ESSENTIALS    OF    DIAGNOSIS. 

its  course  up  to  the  moment  of  examination),  it  becomes  neces- 
sary to  interpret  the  information  thus  gained — in  other  words, 
to  make  a  diagnosis. 

In  making  a  diagnosis  one  has  to  consider  not  only  the  bear- 
ing of  the  signs  and  symptoms  individual!}'  and  collectively, 
but  also  their  relations  with  the  phenomena  of  health  and  with 
each  other.  Further,  one  has  to  consider  (and  this  is  what 
ma}',  to  some  extent,  be  learned  from  reading)  the  historical 
experience  of  the  medical  profession  as  to  the  significance  of 
certain  symptoms  and  groups  of  symptoms,  and  as  to  the  rela- 
tion of  certain  symptoms  and  groups  of  symptoms  with  lesions 
observed  ^jost  mortem. 

A  diagnosis  may  thus  be  made  (1)  by  the  inductive  method^ 
reasoning,  upon  anatomical  (structural)  and  physiological  (func- 
tional) data,  from  the  character  of  the  disturbance  to  the  organ 
affected  and  the  nature  of  the  affection  ;  (2)  by  the  historical  or 
emxtiriccd  method,  relying  upon  the  recorded  experience  of  other 
observers  and  upon  one's  own  experience  that  certain  symp- 
toms manifested  under  certain  circumstances  indicate  the 
existence  of  a  definite  malady  ;  or  (3)  by  the  method  of  x>(dho- 
logical  association,  which  is  based  upon  the  fact  that  when 
certain  symptoms  have  been  observed  during  life,  definite 
lesions  have  been  discovered  after  death.  By  analogy,  the  les- 
sons of  pathological  association  may  be  applied  in  aftections 
not  necessarily  of  a  fatal  character.  It  is  obvious,  therefore, 
that  a  knowledge  of  the  various  gross  and  minute  morbid 
changes  occurring  in  the  body  generally  or  in  special  organs, 
tissues  or  cells  and  of  the  circumstances  under  which  special 
changes  are  likely  to  occur  is  essential  for  precision  in  diagnosis. 
The  most  satisfactory  results  are  to  be  obtained  when  ah  of  the 
methods  indicated  can  be  concurrently  availed  of. 

Diagnosis  may  further  be  direct,  differential  or  by  exclusion. 
Diagnosis  is  said  to  be  direct  when  one  or  more  of  the  signs  or 
symptoms,  independently  of  or  in  relation  with  other  symptoms 
or  with  the  age,  sex,  physical  and  mental  characteristics,  resi- 
dence or  occupation  of  the  patient,  or  with  his  family  history, 
enable  direct  affirmation  to  be  made  of  the  nature  of  the  malady. 
Thus,  a  paroxysm  of  chill,  fever  and  sweating,  in  association 


INTRODUCTION.  21 

with  the  presence  in  the  blood  of  characteristic  parasites,  per- 
mits a  direct  diagnosis  of  malarial  fever  to  be  made. 

Diagnosis  is  said  to  be  discriminative  or  differential  when  the 
signs  or  symptoms  are  suggestive  of  more  tlian  one  disease  and 
a  decision  is  reached  by  comparison  and  contrast.  It  is  neces- 
sary to  compare  the  ideal  pictures  of  various  diseases  in  turn 
with  the  actual  picture  presented,  in  order  to  establish  the 
resemblance  or  unlikeness ;  finally  affirming  the  nature  of  the 
case  with  more  or  less  certainty,  according  to  the  completeness 
and  definiteness  of  the  observations  made  and  the  degree 
of  knowledge  on  the  part  of  the  clinician  as  to  the  conditions 
present  in  the  respective  affections  under  review.  Diagnosis 
is  usually  differential,  and  as  one  is  often  compelled  to  balance 
probabilities,  with  incomplete  evidence  before  him,  differential 
diagnosis  calls  for  the  greatest  knowledge  and  skill.  Xumerous 
examples  of  differential  diagnosis  will  be  found  throughout  this 
book.  Reference  may  here  be  made  to  malarial  fever,  in  case 
hematozoa  are  not  demonstrable,  and  the  fever  of  hepatic  sup- 
puration or  of  pulmonary  tuberculosis.  Careful  observation  of 
the  temperature-course  and  painstaking  physical  examination 
may  be  required  to  establish  the  points  of  difference. 

In  diagnosis  by  exclusion  one  is  unable  to  affirm  the  nature  of 
the  affection  directly  ;  and  even  after  comparison  of  the  evident 
phenomena  with  the  phenomena  of  the  respective  diseases  sug- 
gested, the  points  of  resemblance  are  not  sufficiently  great  in 
number  or  in  character  to  warrant  an  affirmative  conclusion  in 
any  one  instance.  It  then  becomes  necessary  to  prove  a  nega- 
tive ;  to  do  which,  reliance  must  be  placed  entirely  upon  points 
of  unlikeness.  One  endeavors  to  recall  in  the  ideal  picture  of  a 
certain  malady  some  s^-mptom  or  association  of  symptoms  so 
necessary  that  its  absence  from  the  actual  case  may  warrant  a 
decided  negative  ;  or,  on  the  other  hand,  to  discover  in  the  case 
before  him  some  symptom  or  association  of  sj'mptoms  so  in- 
compatible with  the  ideal  picture  of  the  malady  under  consid- 
eration as  likewise  to  warrant  a  negative  conclusion.  Thus, 
from  the  absence  of  what  ought  to  be  present  and  from  the 
presence  of  what  ought  to  be  absent,  one  after  another  of  the 
conditions  discussed  is  set  aside,  until  finally  one  remains  that 


22  ESSENTIALS    OF    DIAGNOSIS. 

cannot  be  so  excluded  ;  and  there  is  reached  a  more  or  less 
probable  diagnosis. 

Diagnosis  by  exclusion  is  the  least  satisfactory,  as  one  can 
never  be  sure  that  he  has  passed  in  review  and  has  excluded  all 
of  the  conditions  that  ought  to  be  excluded.  Nevertheless,  it 
sometimes  affords  most  brilliant  results.  Thus,  paralysis  of  the 
left  vocal  band,  associated  with  recurring  cough  and  occasional 
dyspnea  and  dysphagia,  every  other  suggested  cause  for  which 
has  been  excluded,  has  led  to  a  correct  diagnosis  of  aneurism  of 
the  arch  of  the  aorta,  not  discoverable  bj-  the  most  careful 
physical  exploration. 

As  a  rule,  that  diagnosis  that  best  and  most  readily  accounts 
for  all  of  the  symptoms  is  the  most  likely  to  be  correct.  When 
any  symptom  is  unaccounted  for,  the  diagnosis  is  at  least  in- 
complete, if  not  doubtful.  Diagnosis  of  a  common  disease, 
other  things  being  equal,  is  more  likely  to  be  correct  than  diag- 
nosis of  a  rare  disease.  On  the  other  hand,  statistics  have  no 
bearing  upon  the  individual  case  ;  the  rare  disease  may  be 
present  and  be  overlooked,  from  want  of  knowledge  or  in  conse- 
quence of  superficial  examination. 

More  than  one  disease  may  be  present  in  the  same  patient  at 
the  same  time  ;  but  certain  diseases  are  held  to  be  antagonistic 
and  thus  not  likely  to  coexist.  Data  bearing  on  this  point  are 
defective  and  are  undergoing  revision  and  correction.  Not  a 
few  cases  have  been  recorded  contradictory  of  some  of  the 
teachings  of  the  past.  Hence,  in  this  work,  little  stress  has 
been  laid  upon  these  antagonisms.  On  the  other  hand,  there 
are  many  lesions  and  morbid  processes  that  are  frequently  found 
associated.  Such  associations  are  specifically  mentioned  where- 
ever  it  seemed  likely  that  a  knowledge  of  their  existence  would 
be  of  service. 

One  disease  sometimes  strongly  predisposes  to  another.  A 
knowledge  of  facts  of  this  nature  is  often  of  assistance  in  diag- 
nosis, as  well  as  in  preventive  treatment. 

A  knowledge  of  the  complications  and  sequel<x  that  ordinarily 
or  exceptionally  attend  or  follow  certain  diseases,  independently 
of  its  bearing  upon  therapeutics,  is  an  important  equipment 
for  the  diagnostician.     This  can  be  acquired  only  by  extensive 


INTRODUCTION.  •  23 

reading  or  by  prolonged  experience.  In  anticipation  of  the  latter 
source  of  information,  the  former  must  be  sedulously  cultivated. 
In  default  of  such  knowledge,  the  mistake  may  be  made  of 
diagnosticating  a  single  well-marked  condition,  as,  for  instance, 
pleuritis,  as  the  whole  of  the  disease  ;  when,  in  reality,  the  con- 
dition may  be  but  a  comparatively  unimportant  complication  in 
the  course  of  typhoid  fever  or  of  an  hepatic  abscess.  Similarly, 
a  sequela  to  some  acute  disease,  remote  in  time  or  obscure  in 
symptoms,  may  be  diagnosticated,  prognosticated  and  treated 
as  an  independent  afiection,  often  to  the  grave  detriment  of  the 
patient.  Thus,  a  temporary  loss  of  knee-jerk  following  un- 
recognized diphtheria  has  led  to  an  incorrect  diagnosis  of  loco- 
motor ataxia.  Sometimes  the  initial  phenomena  of  disease 
escape  observation  (a  chancre  may  be  concealed,  especially  in 
the  female,  or  scarlatina  may  occur  without  eruption  or  appre- 
ciable fever,  thermometry  not  being  resorted  to),  and  when  the 
later  phenomena  (such  as  syphilitic  fever  or  scarlatinal  dropsy) 
develop,  the  case  may  be  misinterpreted,  unless  this  possibility 
of  masked  beginnings  be  borne  in  mind. 

The  so-called  negative  signs  of  disease  should  not  be  under- 
rated. The  absence  of  headache  may  assist  in  the  exclusion  of 
brain-tumor  ;  the  absence  of  albumin  and  casts  from  the  urine, 
after  sufficiently  careful  and  extended  observation,  may  be  of 
great  importance  in  discriminating  among  the  causes  of  a  train 
of  symptoms  including  vertigo,  optic  neuritis,  vomiting  and 
paroxysmal  dyspnea  ;  the  absence  of  rose-rash  and  of  splenic 
enlargement  ma}^  determine  the  diagnosis  between  enteric  in- 
fluenza and  typhoid  fever.  In  recording  cases  it  is  necessary  to 
note  negative  points  in  order  to  show  that  the  inquiry  or  search 
has  been  made. 

No  less  important  is  a  knowledge  of  the  morbid  phenomena 
that  may  be  caused  by  certain  drugs — not  merely  bj'  the  narcotic 
agents,  opium,  belladonna,  and  the  like,  but  by  such  poisons  as 
mercury,  arsenic  and  lead,  which  may  produce  symptoms 
closely  resembling  acute  and  chronic  diseases  of  common  occur- 
rence or  may  give  rise  to  nervous  and  other  phenomena  puzzling 
in  the  extreme.  Similar!}',  common  or  unusual  drug-effects, 
perhaps  due  to  idiosyncrasy,  occurring  in  the  course  of  treat- 


24  ESSENTIALS    OF    DIAGNOSIS. 

ment,  may  mask  the  symptoms  of  disease,  or  give  rise  to  addi- 
tional phenomena  that,  unless  caution  be  exerc-ised,  may  lead  to 
error  in  diagnosis. 

The  data  for  diagnosis  are  obtained  by  observation  and  inquiry. 

Inquiry  may  often  have  to  be  made  of  those  about  the  patient, 
the  latter  being  unable  or  incompetent  to  answer  ;  and  not 
rarely  the  same  questions  will  have  to  be  repeated  in  various 
ways  and  be  controlled  by  questions  requiring  opposite  answers, 
in  order  that  the  clinician  be  not  deceived,  intentionally  or 
otherwise. 

Obseri-ation  can  be  made  while  the  questioning  is  proceeding  ; 
sometimes  the  manner,  method  and  form  of  a  patient's  answers 
to  questions  are  in  themselves  part  of  the  data  acquired  by  ob- 
servation. For  example,  in  cases  of  aphasia,-  the  patient  is 
unable  to  find  words  in  which  to  express  himself,  though  he 
may  understand  the  questions  put  and  may  even  believe  that  in 
his  monotonous  repetition  of  certain  words  and  phrases  he  has 
given  an  intelligent  answer. 

Observation  includes  (1)  a  more  or  less  rapid  survey  of  the 
general  condition  of  the  patient,  and  (2)  a  careful  examination 
into  the  condition  of  special  structures,  the  performance  of  special 
functions  and  the  constitution,  chemic  and  microscopic,  of  the 
blood,  the  secretions  and  the  excretions,  both  as  to  normal  and 
abnormal  constituents. 

The  whereabouts  of  the  patient  may  afford  information  as  to 
the  acuteness  or  severity  of  the  attack.  He  may  be  attending 
to  his  work  as  usual,  or  he  may  be  confined  to  his  house,  his 
room,  his  bed. 

Position  and  movement  are  next  noted.  Thus,  if  the  patient 
paces  restlessly  about,  a  condition  of  excitement,  of  physical  or 
mental  causation,  is  indicated.  If,  wiiether  seated  or  recumbent, 
his  position  is  easy  and  unconstrained,  it  indicates  that,  what- 
ever the  disease  may  be,  the  atta,ck  is,  for  the  time  being,  mild 
and  that  there  is  no  serious  respiratory  or  circulatory  trouble, 
or  inflammation  of  an  important  part.  If  the  patient  lie  pass- 
ively upon  his  baclv,  or  huddled  up  in  a  heap,  a  prostrating  sick- 
ness, usuall}''  an  acute  infectious  disease,  is  indicated.  If  he  lie 
persistently  on  one  side,  affection  of  the  lung  or  pleura  of  that 


INTRODUCTION.  25 

side  is  likely  to  exist ;  because  this  position  restrains  the  move- 
ment of  that  side  of  the  thorax,  lessens  the  pain  of  acute  in- 
flammation aud,  in  addition,  permits  the  healthy  lung  to  better 
perform  its  work.  Sometimes,  however,  patients  with  pneu- 
monia lie  on  the  sound  side,  having  less  pain  in  that  posture. 

If,  whether  the  patient  be  in  an  easy-chair,  or  in  bed,  the 
thorax  is  propped  into  an  upright  or  semi-upright  posture, 
there  is  great  difficulty  in  respiration  {orthopnea)^  which  may  be 
be  due  to  cardiac  or  pulmonary  disease,  to  obstruction  in  the 
upper  air-passages,  or  to  abdominal  or  general  effusions.  If  the 
patient  lie  upon  his  back  with  the  legs  drawn  up,  there  is  likely 
to  be  peritonitis,  and  if  on  the  right  side  with  the  right  leg 
drawn  up,  appendicitis  should  be  suspected. 

If  the  head  is  retracted,  or  fixed  in  opisthotonos,  disease  of 
the  cerebrum  or  of  the  meninges  is  to  be  suspected.  So,  too, 
deviation  of  the  head  to  one  or  the  other  side,  picking  at  the 
bedclothes,  helplessness  of  one  or  more  extremities,  general 
restlessness,  jactitation,  local  spasms  or  general  convulsions, 
incoordination,  tremor,  temporary  or  persistent,  sometimes 
throw  considerable  light  on  the  condition  of  the  nervous  system. 

The  expression  of  the  countenance  should  be  observed.  It  may 
be  indicative  of  comparative  comfort  or  of  intense  suffering  ;  it 
may  be  dull  and  apathetic,  as  in  typhus  fever  ;  sunken  and 
anxious,  as  in  cholera  ;  eager  aud  brilliant,  as  in  some  cases  of 
pulmonary  tuberculosis  ;  indeed,  a  careful  study  of  the  physiog- 
nomy of  patients  may  often  directly  reveal  much,  or  indirectly 
serve  to  lead  the  attention  of  the  examiner  to  matters  that  might 
otherwise  be  overlooked.  Thus,  there  is  in  man}'  cases  of  chronic 
nephritis  a  peculiar  pallor  that  can  hardly  be  mistaken  by  the 
experienced  observer.  Connected  with  the  expression  of  the 
face  are  the  general  nutrition,  the  condition  of  the  slin,  and  the 
condition  of  the  mind^  all  of  which  must  be  included  in  the 
general  examination. 

Concerning  the  mental  condition,  without  special  effort  it  can 
be  learned  whether  the  patient  is  interested  in  his  surroundings 
or  is  oblivious  to  them,  whether  he  is  conscious  or  unconscious, 
whether  he  is  delirious  or  is  aware  of  his  sayings  and  doings, 
whether  he  is  able  to  fix  his  attention  or  is  continually  wander- 


26  ESSENTIALS    OF    DIAGNOSIS. 

ing.  To  the  facts  developed  on  special  inquiry  no  attention  is 
now  being  paid. 

The  shin  may  be  of  normal  hue,  pallid  from  impoverishment 
of  blood,  flushed  with  fever,  discolored  by  inflammations,  bruises, 
extravasations,  eruptions,  jaundice,  the  various  cachexias.  It 
may  be  swollen,  or  give  evidence  of  swelling  or  eflusion  beneath. 
It  may  be  abnormally  smooth  or  rough,  dry  or  moist,  hot  or 
cold. 

The  state  of  the  nutrition  is  usually  evident  in  the  preservation 
of  the  full,  rounded  outlines,  or  in  the  sharpness  and  hollows  of 
emaciation.  For  accuracy  and  completeness  of  knowledge  the 
weight  should  be  determined  by  the  scales. 

Abnormal  prominences  of  various  kinds  and  situation  may  in- 
dicate the  existence  of  tumors^  effusions,  articular,  osseous,  glan- 
dular and  visceral  enlargements  of  inflammatorj^  or  other  origin, 
to  be  determined  by  further  examination. 

Pulsations  may  be  visible  that,  by  their  abnormal  situation  or 
abnormal  character,  are  indicative  of  abnormal  circulatory  con- 
ditions, or  of  tumors  or  collections  of  fluid  external  to  the  heart 
or  vessels.  Tlie  tortuosity  of  visible  arteries,  or  the  localized  or 
general  turgescence  of  superficial  veins,  may  indicate  disease  or 
obstruction  in  or  afl*ecting  the  circulatory  apparatus. 

The  manner  in  which  'breathing  is  performed,  the  character  of 
the  voice,  the  nature  of  a  cough,  afford  information  as  to  the  con- 
dition of  the  respiratory  apparatus. 

Examination  of  the  jjulse,  the  tongue,  and  the  temperature,  while 
affording  general  indications,  yet  mark  the  transition  from 
general  to  special  examinations. 

Except  in  a  few  instances,  the  plan  of  this  book  does  not  con- 
template descriptions  of  methods  of  special  examination,  or 
enumeration  of  the  conditions  indicated  by  special  symptoms 
and  signs  {semeiology,  inductive  diagnosis),  but  rather  an  account 
of  the  observed  clinical  groupings  of  signs  and  symptoms  in  the 
recognized  and  named  affections  of  nosology  [historical  diagnosis, 
pathological  association  diagnosis),  and  an  elucidation  of  the 
points  of  contrast  between  diseases  most  likely  to  be  confounded 
{differential  diagnosis). 


FEVER.  27 


FEVER. 

What  is  fever  ? 

Fc-ver  is  a  complex  morbid  process,  of  which  the  most  striking 
feature  is  elevation  of  temperature.  Sometimes  the  term  fever 
is  restricted  to  the  abnormal  heat,  hut  this  is  more  correctly 
termed  pyrexia.  In  addition  to  p3'rexia,  fever  is  attended  with 
acceleration  of  the  pulse  and  of  the  respiration,  with  thirst  and 
with  disturbance  of  digestion.  There  are  likewise  increased 
and  jierverted  tissue-changes,  as  manifested  by  alterations  of 
secretions  and  excretions,  which  may  be  completel}-  arrested  or 
diminished  in  quantity  and  changed  in  quality.  As  a  result  of 
the  deprivation  of  the  normal  products  of  metabolism  and  of  the 
retention  in  the  blood  of  abnormal  products  of  metabolism,  as 
well  as  of  the  waste-products  of  normal  metabolism,  other  sj'mp- 
toms  are  often  caused,  such  as  malaise,  depression,  headache, 
insomnia,  delirium,  etc.  When  fever  is  long-continued,  wasting 
takes  place ;  partly  as  a  result  of  the  abnormal  heat,  both  di- 
rectly and  indirectly  ;  partly  from  other  causes.  Many  febrile 
processes  are  at  some  period  in  their  course  attended  with  sub- 
normal temperature. 

What  is  the  average  normal  temperature  of  man  ? 

The  average  normal  temperature  of  the  adult  is  98.4°  or  98.6°  F. 
(37^  C.)  ;  in  health  it  may  vary  from  this  a  little  more  than  a 
degree  ;  from  97.3^  F.  (36.25^  C.)  to  99.50  F.  (37.5^  C.).  It  is 
higher  in  children  than  in  adults,  and  in  the  asjed  it  is  some- 
times  a  few  tenths  higher  or  lower. 

The  temperature  is  increased  after  meals  by  the  activity  of 
digestion  ;  it  is  increased  by  exertion,  and  in  children  and  hys- 
terical persons  by  emotion.  Weather  has  but  shght  influence 
upon  the  temperature  of  the  healthy;  it  often  has  a  marked  influ- 
ence upon  that  of  the  sick.  There  are  daily  periodic  variations. 
The  daily  minimum  occurs  in  the  early  morning  between  two 
and  Ave  o'clock  ;  the  daily  maximum,  is  reached  between  five  and 
eight  o'clock  in  the  evening.  The  average  diffei^ence  between 
maximum  and  minimum  is  about  1.5^  F.  ;  it  may  be  much 


28  ESSENTIALS    OF    DIAGNOSIS. 

more.  In  the  tropics  the  average  body-heat  is  said  to  be 
slightly  higher,  and  the  daily  range  greater  than  in  temperate 
climates. 

In  sickness  the  diurnal  variations  (morning  remission,  evening 
exacerbation)  become  quite  marked. 

What  is  subfebrile  temperature  ? 

The  term  suhfehriJe  temperature  is  not  to  be  confounded  with 
syhnormal  temperature.  It  is  applied  to  a  moderate  morbid  ele- 
vation of  temperature  not  exceeding  100.4°  F.  (SS'^  C). 

What  is  the  ordinary  range  of  febrile  temperature  ? 

A  temperature  of  from  100.4°  F.  (38°  C.)  to  101.2O  F.  (38.40C.) 
is  considered  an  indication  of  slight  fever. 

A  temperature  of  from  101.3°  F.  (38.5°  C.)  to  102.2°  F.  (39°  C.) 
in  the  morning,  and  of  103°  F.  (39.5°  C)  in  the  evening,  is  in- 
dicative of  moderate  fever. 

A  temperature  of  from  103°  F.  (39.5°  C.)  to  104°  F.  (40°  C.) 
in  the  morning,  and  of  105°  F.  (40.5°  C.)  in  the  evening,  indi- 
cates hiyli  fever. 

What  is  hyperpyrexia? 

Febrile  temperature  exhibiting  a  tendency  to  remain  above 
107°  F.  (41.7°  C.)  is  called  liyperpyrexia.  This  is  ordinarily 
directly  dangerous  to  life. 

Yery  high  temperatures  have  been  observed  in  hysterical 
cases  in  which,  apparently,  deception  has  been  guarded  against ; 
a  case  of  injury  to  the  spine,  in  which  recover}-  took  place,  is 
reported  to  have  exhibited  on  many  occasions  a  temperature  of 
122°  F.  (50°  C). 

What  is  meant  by  inverse  temperature? 

Ordinarily  the  course  pursued  b}*  morbid  temperature  is  like 
that  of  normal  temperature  in  having  its  maximum  towards 
evening,  and  its  minimum  in  the  early  morning.  Sometimes, 
however,  the  maximum  may  be  much  earlier  or  much  later  than 
usual,  even  at  noon  or  at  midnight.  Sometimes  there  arc  great 
fluctuations  during  day  and  night.  When  a  complete  reversal 
takes  place,  so  that  the  morning  temperature  exhibits  the  maxi- 


FEVER.  29 

mum,  and  the  evening  temperature  the  minimum,  the  condition 
is  said  to  be  one  of  "inverse  temperature." 

Inverse  temperature  not  infrequently  occurs  in  acute  tubercu- 
lous aflections.    It  is  of  rather  rare  occurrence  in  typhoid  fever. 

What  is  the  significance  of  a  sudden  fall  of  temperature  ? 

A  sudden  fall  of  temperature  may  be  part  of  the  usual  phe- 
nomena of  a  disease,  as  in  intermittent  fever  ;  or  it  may  indi- 
cate termination  by  crisis,  as  in  pneumonia ;  or  when  it  is  not 
part  of  the  usual  course,  and  is  not  brought  about  by  obvious 
loss  of  blood  (as  by  venesection  or  menstruation),  by  drugs  or 
cold  applications,  or  other  extraneous  intlueuce,  it  may  indicate 
the  development  of  albuminuria,  or  the  occurrence  of  internal 
hemorrhage. 

What  is  subnormal  temperature  ? 

A  temperature  lower  than  97.3^  F.  (36.25°  C.)  is  considered 
subnormal. 

The  temperature  ma}^  be  subnormal  in  influenza  and  in  acute 
yellow  atrophy  of  the  liver  as  part  of  the  essential  course  of  the 
disease. 

Subnormal  temperature  occurs,  usually  associated  with  pro- 
fuse persjiiration,  at  periods  of  critical  recovery,  as  in  pneu- 
monia. There  is  simultaneous  decrease  in  the  frequency'  of 
pulse  and  of  respiration  and  improvement  in  the  general  con- 
dition and  sensations  of  the  patient.  In  many  acute  diseases 
that  terminate  b}^  h'sis,  such  as  typhoid  fever,  the  temperature 
falls  below  the  normal  with  the  setting  in  of  convalescence. 

A  subnormal  temperature  develops  abruptly  in  conditions  of 
collapse.  It  is  then  associated  with  sudden  failure  of  the  heart, 
as  indicated  by  a  feeble,  rapid  and  irregular  pulse,  a  fluttering 
and  feeble  cardiac  impulse,  pallor,  coldness  of  the  skin,  with  or 
without  sweating,  faintness  or  syncope,  and  profound  prostra- 
tion and  weakness.  The  pulse  becomes  feebler,  less  rapid,  and 
may  finally  cease.  If  recovery  take  place,  the  temperature  again 
rises  ;  or,  if  the  termination  be  fatal,  the  temperature  may  rise 
2J0st  morUm. 

The  temperature  becomes  subnormal  in  some  cases  of  severe 
hemorrhage,  and  at  times,  temporarily  or  persistently,  in  chronic 


30  ESSENTIALS    OF    DIAGNOSIS. 

wasting  diseases,  sucli  as  pulmonary  tuberculosis  and  carci- 
noma, in  chronic  Brigbt's  disease  and  in  some  diseases  of  the 
brain. 

What  is  an  essential  fever  ? 

Au  idiopathic  or  essential  fever  is  one  in  wbicb  the  pyrexia  and 
its  concomitants  do  not  result  secondarily  from  an  anatomical 
lesion,  but  arise  primarily  from  the  action  of  a  specific  poison 
or  a  similar  cause.  Essential  fevers  may  or  ma}^  not  present  in- 
variable lesions  as  a  part  of  their  phenomena. 

What  is  a  symptomatic  fever  ? 

A  symptomatic  or  deittcropathic  fever  is  one  that  arises  second- 
arily as  the  result  of  irritation,  intoxication  or  perverted  func- 
tion, caused  by  disease  or  injury  of  a  special  organ  or  tissue. 
The  causative  lesion  is  the  essential  element  ;  the  fever  is  but 
one  of  the  S3anptoms. 

What  is  a  specific  fever  ? 

A  spjecific  fever  is  an  essential  fever  due  to  a  specific  patho- 
genetic agent.  Typhoid  fever  and  yellow  fever  are  examples  of 
specific  fevers. 

What  is  a  continued  fever? 

A  continued  fever  is  one  in  which  the  temperature  pursues  an 
uninterrupted  course,  without  sudden  variation  from  beginning 
to  end.  The  diurnal  range  will  not  exceed  LS^F.  (V^C).  The 
first  rise  may  be  sudden  or  gradual ;  there  may  be  steady  main- 
tenance of  a  maximum,  or  continuous  increase  ;  there  may  be 
gradual  or  sudden  final  defervescence  ;  but  there  is  not  a  decided 
fall  and  a  renewed  rise  during  the  progress  of  the  case. 

What  is  a  remittent  fever? 

A  remittent  fever  is  one  the  course  of  which  is  interrupted  once 
or  repeatedly  by  a  marked  decline  in  temperature,  not  reaching 
the  normal,  and  followed  by  renewed  exacerbation.  The  daily 
difference  will  exceed  1°  C.  (1.8°  F.). 

What  is  an  intermittent  fever  ? 

An  intermittent  fever  is  one  in  the  course  of  which  a  complete 
intermission  takes  place  once  or  repeatedly  ;  that  is  to  say,  in 


SIMPLE    CONTINUED    FEVER ARDENT    FEVER.       31 

the  progress  of  the  case  the  temperature  becomes  normal  (or 
even  subnormal)^  remains  normal  for  an  appreciable  time,  of 
«Teater  or  less  duration,  and  subsequently  rises  to  about  its 
previous  level.     The  maximum  may  be  high. 

Simple  Continued  Fever. 

What  is  the  clinical  course  of  simple  continued  fever  ? 

Simple  continued  fever,  ephemeral  fever  or  febricula  is  a  non- 
specilic  fever,  sometimes  apparently  idiopathic,  but  often  symp- 
tomatic of  digestive  aberration  or  of  some  local  irritation.  It 
may  be  cciused  by  error  in  diet,  by  fatigue,  anxiety,  shock,  un- 
iisuah  mental  or  physical  exertion,  exposure  to  cold  and  damp, 
to  a  foul  atmosphere,  to  the  sun,  or  to  other  source  of  metabolic 
perversion  giving  rise  to  intoxication. 

The  disease  sets  in  with  a  feeling  of  indisposition,  which  is 
followed  by  chilliness,  fever,  with  heated  skin,  headache,  thirst, 
anorexia  and  pain  in  the  back  and  limbs.  The  pwZse  is  acceler- 
ated. The  tongue  is  coated.  There  is  usually  constipation,  less 
frequently  diarrhea.  The  urine  is  scanty  and  high-colored.  The 
pyrexia  is  slight  or  moderate  ;  the  diurnal  variations  are  small, 
the  rise  rapid,  the  fall  gradual  or  by  critical  defervescence,  with 
profuse  sweating  or  watery  diarrhea.  The  duration  is  commonly 
less  than  a  week.  It  may  be  less  than  twenty-four  hours.  Re- 
covery is  invariable  and  convalescence  is  rapid. 

Graver  forms  of  the  affection,  induced  by  the  graver  causes, 
may  be  attended  with  considerable  depression,  and  running  a 
more  protracted  course,  in  duration  from  ten  to  fourteen  days, 
may  simulate  typhoid  fever.  Especially  is  this  resemblance 
marked  in  cases  of  septic  intoxication. 

Ardent  Fever, 

What  is  ardent  fever  ? 

Ardent  fever  is  a  non-specific,  continued  fever,  occurring  in  hot 
countries,  in  which  the  ordinar}^  symptoms  of  febricula  are 
exaggerated.  The  temperature  reaches  or  exceeds  103*^  F. ;  there 
i§  tbi^obbing  of  the  temporal  arteries,  with  severe  headache  and 


32  ESSENTIALS    OF    DIAGNOSIS. 

even  delirium.  The  symptoms  resemble  those  of  an  inflamma- 
tory fever,  so  that  the  utmost  care  must  be  observed  to  avoid 
error  in  diagnosis. 


Catarrhal  Fever — Influenza. 

What  is  catarrhal  fever  ? 

Catarrhal  fever,  epidemic  catarrh,  influenza  or  la  grippe,  now 
commonly  called  "  grip  "  in  the  United  States,  is  a  widespread 
contagious  disease  that  occurs  epidemically,  endemically  or 
pandemically,  more  rarely  sporadically,  and  exhibits  a  protean 
capability  of  variation  in  its  symptoms.  It  is  dependent  upon 
the  activity  of  a  small  bacillus  with  rounded  extremities  that  is 
found  in  the  nasal  and  bronchial  secretions.  The  period  of 
incubation  is  from  one  to  four  days. 

There  are  four  prominent  varieties  of  the  disease  :  (1)  the  catar- 
rhal, in  which  the  predominant  features  are  those  of  catarrhal 
inflammation  of  the  respiratory  tract ;  (2)  the  thoracic,  in  which, 
with  or  without  the  ordinary  catarrhal  manifestations,  there  are 
symptoms  of  profound  involvement  of  the  thoracic  viscera; 
(3)  the  abdominal  or  gastro-intestinal,  in  which  disturbances  of 
the  digestive  tract  are  most  marked;  (4)  the  nervous  or  cerebral, 
in  which  neural  phenomena  attract  attention,  and  in  which,  as 
in  the  abdominal  variety,  the  clinical  course  of  typhoid  fever  is 
often  closely  simulated.  Much  greater  refinement  in  sub- 
division might  be  made,  as  the  symptoms  of  two  or  more  tj^pes 
are  frequently  associated  in  one  case.  Some  epidemics  are 
characterized  by  greater  or  even  exclusive  prevalence  of  one  or 
two  types ;  but  in  other  epidemics,  half  a  dozen  patients  in  one 
household  may  exhibit  six  varieties  of  the  disease. 

What  is  the  clinical  course  of  influenza  ? 

The  invasion  of  influenza  is  commonly  sudden,  sometimes  with 
a  chill,  usually  with  more  or  less  irritation  or  inflammation  of  the 
mucous  membranes  of  the  nose  and  throat,  often  associated  with 
catarrhal  conjunctivitis  and  blepharitis  (pink-eye).  Epistaxis 
may  occur  at  this  time  or  later.     There  is  always  a  feeling  of 


CATAllRIIAL    FEVER  —  INFLUENZA.  33 

lassitude,  passing  into  unaccountable  depression,  physical  and 
mental,  with  soreness  in  the  back  and  limbs,  aching  of  the 
muscles,  more  or  less  stiffness  of  the  neck,  cutaneous  hyper- 
esthesia, headache,  dyspnea  and  anorexia. 

The  temperature  is  decidedly  irregular;  it  may  rise  high;  it  is 
often  subnormal  for  more  or  less  protracted  periods,  and  is  sub- 
ject to  extreme  fluctuations.  It  may  be  periodically  or  irregu- 
larly remittent  or  intermittent.  The  pulse  is  not  much  accel- 
erated; it  ordinarily  is  weak,  the  heart  sharing  in  the  general 
depression.  The  tongue  is  coated;  the  bowels  are  often  con- 
stipated ;  the  urine  is  scanty  and  high-colored,  or  profuse  and 
light-colored.  The  skin  is  hot  and  dry  and  often  peculiarly 
sensitive  to  the  touch.  Sometimes  there  are  irregular  per- 
spirations. 

In  the  catarrhal  type,  sneezing,  coryza,  watering  of  the  eyes, 
odynphagia,  painful  respiration  and  a  dry,  harassing,  irritative 
cough  are  early  and  prominent  symptoms.  The  difficulty  and 
distress  in  breathing  are  out  of  all  proportion  to  the  phenomena 
elicited  by  auscultation  and  percussion.  Later,  the  cough  be- 
comes freer,  and  associated  with  expectoration  of  a  thick,  glairy 
mucus,  sometimes  blood-streaked  or  discolored  ;  the  nasal  dis- 
charge becomes  thicker  and  even  purulent  and  hemorrhagic. 
Involvement  of  the  sinuses  (frontal,  ethmoid,  maxillary)  may 
cause  excruciating  pain.  With  recovery,  profuse,  watery  diar- 
rhea occurs.  In  some  cases,  symptoms  of  tonsillitis  or  of  ca- 
tarrhal pharyngitis  are  the  earliest,  those  of  laryngitis  and  of 
bronchitis  following.  Coryza  may  be  a  late  manifestation.  In 
some  cases,  there  is  a  peculiar  edematoid  condition  of  the  ton- 
sil, uvula,  and  neighboring  structures  that  has  been  termed 
"solid  edema,"  as  puncture  gives  exit  not  to  serum,  but  to  a 
sanious,  stringy,  lymphoid  material.  Suppurative  otitis  media, 
preceded  by  excruciating  earache  and  usually  affecting  both 
ears  in  succession,  may  be  the  only  manifestation  in  the  upper 
air-tract.  This  otitis  is  quite  common  in  children  and  usually 
runs  through  a  household. 

In  the  thoracic  type,  pleuritis,  pericarditis,  endocarditis,  pneu- 
monia— catarrhal,  croupous,  or  hemorrhagic — or  edematous  or 
3 


34  ESSENTIALS    OF    DIAGNOSIS. 

hemorrhagic  infiltration  of  the  lung  may  cause  grave  symptoms 
or  even  death. 

In  the  abdominal  or  gastro-intestinal  type,  vomiting  and  purging 
are  common,  and  there  may  be  great  pain  and  tenderness  in  the 
epigastrium  or  over  the  entire  abdomen.  Catarrhal  jaundice 
may  occur. 

In  the  cerebral  or  nervous  type,  the  headache  is  intense  ;  there 
may  be  insomnia,  photophobia,  tinnitus  aurium,  talkativeness 
or  even  mild  delirium.  There  is  decided  hyperesthesia  ;  there 
may  be  restlessness,  tremor,  muscular  twitchings  or  jactitations. 

In  the  typhoid  type,  the  course  of  the  disease  may  be  pro- 
tracted, and  the  temperature  may  remain  continuously  elevated. 
The  prostration  may  be  extreme  ;  the  mental  phenomena  may 
be  characterized  by  depression.  There  may  be  epistaxis,  pain 
in  the  splenic  region,  special  tenderness  in  the  right  iliac  fossa 
and  considerable  diarrhea.  There  may  be  anomalous  eruptions 
—papular,  herpetic  or  erythematous.  The  action  of  the  heart 
may  be  exceedingly  feeble.  Heart-failure  is  always  a  threaten- 
ing danger. 

The  duration  of  influenza  is  as  variable  as  are  the  symptoms. 
It  may  be  less  than  forty-eight  hours ;  it  may  be  several  weeks. 
Commonly,  the  acute  symptoms  last  from  three  or  four  days  to 
a  week,  but  the  weakness  and  depression  continue  much  longer. 
Convalescence  may  be  tardy,  prolonged  subnormal  temperature 
and  annoying  perspiration  being  notable  features. 

In  addition  to  the  complications  mentioned,  there  may  be 
hemorrhages  from  various  organs,  meningitis— cerebral  and 
spinal— multiple  neuritis,  arthritis  and  nephritis.  Among  the 
sequelce  are  tuberculosis,  paralyses  of  various  kinds,  hemicrania 
and  melancholia,  and  other  psychoses.  Of  itself  influenza  is  not 
often  fatal  or  directly  provocative  of  serious  complications  or 
sequelae  ;  but  it  aggravates  existing  lesions  or  morbid  processes, 
reawakens  latent  disease  or  searches  out  the  weak  point  in  the 
organism  and  renders  this  liable  to  the  action  of  exciting 
causes.  Hence,  the  great  variability  in  its  clinical  course,  and 
hence,  too,  the  high  mortality  it  occasions  among  the  previously 
sick  and  debilitated,  among  infants  and  the  aged. 


TYPHOID  FEVER ENTERIC  FEVER.       35 

With  what  diseases  may  influenza  be  confounded  ? 

The  diagnosis  of  influenza  may  ])e  extremely  easy  or  ex- 
tremely difficult.  According  to  its  type,  it  may  be  mistaken  for 
simple  catarrhal  inflammation  of  the  mucous  membrane  of  the 
eye,  ear,  nose,  throat,  bronchi,  stomach  or  intestines  ;  for 
measles ;  for  cerebro-spinal  meningitis ;  for  acute  articular 
rheumatism  ;  for  dengue  ;  for  ordinary  types  of  pleurisy  or 
pneumonia ;  for  malarial  fever ;  for  acute  tuberculosis ;  for 
typhoid  fever. 

Upon  what  does  the  discrimination  depend? 

In  times  of  prevalence  of  epidemic  influenza,  or  of. the  analo- 
gous epizooty,  the  knowledge  of  that  fact  will  cause  one  to  be 
on  the  lookout  for  the  disease,  and  he  may,  perhaps,  even  call 
other  affections  by  its  name.  Characteristics  upon  which  stress 
should  be  placed  are  the  sudden  onset,  the  great  depression, 
the  cutaneous  hyperesthesia,  the  lumbar  and  muscular  pains 
and  -the  excessive  respiratory  distress.  These  serve  to  distin- 
guish it  from  indigestion,  gastro-intestinal  catarrh,  bronchitis, 
coryza  and  "  colds."  In  contradistinction  from  typhoid  fever  or 
typhus  fever,  the  common  occurrence  of  some  form  of  catarrhal 
symptoms,  the  irregularity  of  the  temperature,  the  shorter  dura- 
tion and  the  absence  of  the  characteristic  symptoms  to  be  de- 
scribed, are  additional  discriminating  points.  From  ordinary 
pneumonia  influenza  differs  in  evolution,  course  and  temper- 
ature, in  the  marked  depression,  in  the  irregular  distribution  of 
the  pulmonary  lesions,  and  in  the  presence  in  the  expectorated 
matters  of  distinctive  bacilli.  The  differential  diagnosis  from 
the  other  diseases  mentioned  will  be  successively  developed. 

Typhoid  Fever — Enteric  Fever. 

What  is  typhoid  fever  ? 

Typhoid  or  enteric  fever  is  an  acute,  infectious  disease,  depen- 
dent upon  a  specific  microorganism,  and  presenting  inflam- 
mation, swelling,  softening  and  ulceration  of  the  intestinal 
lymphatic  structures,  enlargement  and  softening  of  the  mesen- 
teric glands,  tumefaction  of  the  spleen,  and  changes  in  the 
parenchyma  of  other  organs.     Rarely  the  intestines  escape. 


36  ESSENTIALS    OF    DIAGNOSIS. 

The  disease  runs  a  course  of  about  twenty-four  days,  beginning 
gradually  and  terminating  by  lysis.  It  is  most  common  in 
young  adults  and  in  the  autumn. 

The  typhoid-bacillus  (Fig.  1)  is  a  plump,  motile  organism,  with 
rounded  extremities.  It  is  about  one-third  as  long  as  the  diam- 
eter of  a  red  blood-corpuscle  and  one-third  as  wide  as  it  is  long. 
It  presents  a  characteristic  growth  upon  potatoes  and  does  not 
liquefy  gelatin.     It  is  best  stained  by  means  of  an  alkaline  solu= 

Fig.  1. 


Bacilli  of  typhoid  fever.     ("Von  Jaksch.) 

tion  of  methylene-blue  or  b}'-  carbol-fuchsin  or  anilin-water 
fuchsin.  It  differs  from  other  organisms  found  in  the  stools  in 
not  generating  indol.  The  bacillus  has  been  found  during  life 
in  the  blood,  in  the  urine,  in  the  stools,  in  the  sputum  and  in 
the  sweat;  and,  after  death,  in  the  intestinal  wall,  in  the  mesen- 
teric glands,  in  the  spleen,  in  the  bone-marrow,  in  the  liver,  in 
the  bile,  and  in  the  midst  of  complicating  lesions. 

How  is  the  disease  acquired  ? 

Typhoid  fever  is  most  commonly  transmitted  through  pol- 
luted water,  though  direct  contagion  and  conveyance  through 
air  or  food  may  take  place. 

What  is  the  clinical  course  of  typhoid  fever  ? 

The  period  of  incubation  of  enteric  fever  varies  between  eight 
and  twenty-three  days.    The  onset  is  usually  insidious,  occasion- 


TYPHOID  FEVER — ENTERIC  FEVER.       37 

ally  abrupt,  with  a  chill.  The  prodromal  period  is  characterized 
by  headache,  pains  in  the  back,  epistaxis,  general  malaise,  dis- 
turbed sleep,  loss  of  appetite  and  coated  tongue.  These  symp- 
toms become  aggravated,  while  to  them  are  added  relaxation 
of  the  bowels,  abdominal  tenderness,  especially  in  the  right  iliac 
fossa,  intestinal  gurgling  and  elevation  of  temperature. 

The  tempefrature  pursues  a  characteristic  course.  (Fig.  2.) 
There  is  a  period  of  gradual  ascent  (first  week),  a  period  of 
maintained  height  (second  week  and  half  of  third  week),  and  a 
period  of  gradual  fall  (last  half  of  third  week  and  fourth  week). 
For  from  five  to  seven  days  the  temperature  rises  two  or  three 
degrees  each  evening,  to  recede  a  degree  or  a  degree  and  a  half 
on  the  following  morning,  until  it  has  reached  a  level  of  from 
102.5'^  to  104^  F.  (in  grave  cases  even  higher),  at  which,  with 

Fig.  2. 
il"  C. 


40°  C. 

39°  C. 

38°  C. 

37°  C. 


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Temperature-chart  of  a  case  of  typhoid  fever.     (Wunderlich.) 

slight  evening  remissions  and  morning  exacerbations,  it  lingers 
for  from  ten  to  fourteen  days,  then  to  decline  inversely  pretty 
much  as  it  rose,  until,  with  the  setting  in  of  convalescence,  it 
may  fall  below  the  normal.  Karely,  the  temperature  does  not 
rise  above  the  normal. 

The  pulse  is  accelerated,  but  not,  as  a  rule,  in  proportion  to 
the  rise  of  temperature.  It  may  not  exceed  90.  It  is  peculiarly 
soft  and  rebounding,  giving  rise  to  an  apparent  duplication 
known  as  dicrotism.  The  tongue  is  coated  in  the  middle,  but 
red  at  the  margins  and  tip.     The  coating  is  thick  and,  at  first. 


38  ESSENTIALS    OF    DIAGNOSIS. 

white.  The  red,  uncoated  portion  at  the  tip  occupies  a  charac- 
teristic wedge-shaped  area.  The  lips,  gums  and  teeth  become 
covered  with  sordes.  The  patient  often  exhales  a  characteristic 
odor.     The  pupils  are  dilated.    A  limited  flush  colors  the  cheek. 

Toward  the  end  of  the  first  week  or  early  in  the  second,  a 
varying  number  of  small,  slightly  elevated,  rose-colored  spots 
that  disappear  upon  pressure  or  upon  stretching  the  skin  may 
be  observed  upon  the  trunk — upon  the  abdomen  or  chest,  ante- 
riorly or  posteriorly.  These  spots  appear  in  successive  crops, 
each  of  which  lasts  for  several  days.  A  diffuse,  scarlatiniform 
erythema  has  been  observed  in  some  cases,  and  an  eruption 
resembling  that  of  measles  or  typhus  in  other  cases. 

The  lupine  presents  a  characteristic  reaction.  If  to  one  part 
of  a  (one-half  per  cent.)  solution  of  sodium  nitrite  in  distilled 
water  (1  :  40)  and  forty  parts  of  a  saturated  solution  of  sulph- 
anilic  acid  in  dilute  hydrochloric  acid  (1  :  20)  is  added  an  equal 
bulk  of  urine  and  the  whole  is  rendered  alkaline  with  ammonia- 
water,  a  deep-red  color  is  produced. 

The  blood  also  yields  a  distinctive  reaction  after  the  first  week, 
causing  agglutination  and  sedimentation  of  typhoid  bacilli,  with 
loss  of  motility,  when  added  in  dilution  of,  say,  1  to  20  to  a 
bouillon-culture — Widal's  reaction.  The  number  of  red  blood- 
corpuscles  and  the  percentage  of  hemoglobin  undergo  reduc- 
tion, while  the  number  of  colorless  corpuscles  is  but  little 
changed.  Generally  the  large  mononuclear  and  transitional 
leukocytes  are  increased,  while  the  polynuclear  neutrophiles 
are  diminished. 

The  palms  of  the  hands  and  the  soles  of  the  feet  sometimes 
present  a  peculiar  yellowish  discoloration. 

In  classically  tyjDical  cases,  there  is  diarrhea ;  but  in  almost 
an  equal  number,  however,  the  bowels  are  constipated.  The 
diarrheal  stools  present  a  characteristic  appearance,  being  thin 
and  yellowish,  "ochrey,"  or  like  pea-soup;  they  have  a  pecul- 
iar, fetid  odor ;  sometimes  they  contain  blood,  independently 
of  a  formal  hemorrhage.  Tympanites  is  common.  The  area  of 
splenic  percussion-dulness  is  increased.  In  the  second  week,  if 
not  earlier,  mental  dulness  and  listlessness  are  manifest.  The 
patient  pays  little  heed  to  his  surroundings,  but  usually  re- 


TYPHOID  FEVER ENTERIC  FEVER.       39 

sponds  when  spoken  to.  Deafness  and  visual  disturbances  are 
not  uncommon,  and  there  is  frequently  low  delirium.  In  the 
third  week,  the  first  sound  of  the  heart  is  observed  to  be  feeble  ; 
emaciation  is  decided,  and  the  tongue  often  becomes  dry,  fissured 
and  coated  with  a  heavy,  brown  fur.  Intestinal  hemorrhage 
may  occur.  Perforation  of  the  bowel,  with  consecutive  peri- 
tonitis, is  among  the  dangers. 

Usualh'-,  towards  the  end  of  the  third  or  the  beginning  of  the 
fourth  week,  progressive  improvement  is  manifested,  coinci- 
dently  w^ith  the  decline  of  temperature.  The  morning  remissions 
exceed  the  evening  rises.  Commonly  by  the  twenty-fourth  day, 
but  often  much  later,  the  temperature  has  fallen  to  the  norm. 
Convalescence  is  slow. 

Death  may  take  place  in  or  after  the  second  week,  from  exhaus- 
stion,  toxemia,  fever  or  the  accidents  of  the  disease. 

Other  comjjUcations  and  sequeJce  than  those  mentioned  are  bed- 
sores, phlebitis,  thrombosis,  pericarditis,  endocarditis,  paro- 
tiditis, edema,  inflammation  or  ulceration  of  the  larynx,  bron- 
chitis, pleuritis,  pneumonia,  pulmonary  tuberculosis,  osteo- 
myelitis, meningitis,  peripheral  neuritis,  nephritis,  orchitis, 
rupture  of  the  spleen,  cholecystitis,  cholangitis,  abscess  of  the 
liver,  the  formation  of  abscesses  and  gangrene. 

Sometimes  the  symptoms  are  mild,  constituting  ambulatory 
or  icalking  typhoid  fever.  At  other  times,  the  attack,  while  per- 
haps severe,  terminates  at  the  end  of  a  week,  or  of  two  weeks, 
constituting  abortive  typhoid  fever.  A  few  days  after  convalescence 
has  set  in,  the  temperature  may  again  rise,  and  the  attack  be 
repeated,  though  curtailed  in  duration,  constituting  a  relapse. 
A  relapse  may  likewise  interrupt  the  declining  course  of  the 
disease.  Sometimes,  when  convalescence  is  apparently  about 
to  set  in,  the  temperature  reascends  and  remains  elevated  for 
an  uncertain  period,  constituting  a  recrudescence. 

What  is  the  distinction  between  a  relapse  and  a  recrudescence 
in  typhoid  fever  ? 
A  typical  relapse  in  typhoid  fever  includes  a  redevelopment 
of  the  entire  group  of  morbid  phenomena  of  the  primary  disease, 
as  indicated  by  a  characteristic  temperature-curve,  splenic  en- 
largement and  rose-rash,  though  the  duration  may  be  shortened. 


40 


ESSENTIALS   OP   DIAGNOSIS. 


A  recrudescence  refers  only  to  a  reappearance  of  fever.  The  tem- 
perature of  recrudescence  does  not  pursue  a  typical  course ;  it 
may  fall  as  suddenly  as  it  rose.  A  recrudescence  may  depend 
upon  some  complication  or  some  accidental  source  of  irritation, 
e.  g.,  peritonitis,  or  constipation  or  the  premature  or  injudicious 
taking  of  food.  A  relapse  indicates  renewed  activity  of  the  spe- 
cific cause  of  the  disease. 

Fig.  3. 


104°  F. 

103°  F. 
lo2°  F. 
101°  F. 

100°  F. 
99°  F. 
98  OF. 


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Temperature-chart  of  relapse  in  typhoid  fever.     Convalescence  from  the  relapse 
interrupted  by  recrudescence.     (From  a  case  at  the  Philadelphia  Hospital.) 

How  is  perforation  of  the  bowel  in  typhoid  fever  to  be  recog- 
nized ? 
Perforation  of  the  bowel  in  the  course  of  typhoid  fever  may 
or  may  not  be  preceded  by  intestinal  hemorrhage.  When  it 
occurs,  the  patient  experiences  a  sudden  and  intense  pain,  local- 
ized at  one  spot  in  the  abdomen,  but  soon  extending.  There 
may  also  be  rigors.  Tympanites,  if  absent,  develops  ;  if  present, 
it  increases.  Vomiting  may  occur.  There  is  exquisite  abdom- 
inal tenderness  ;  the  patient  lies  upon  his  back,  with  the  legs 
drawn  up  ;  tlie  face  is  pale,  pinched  and  anxious ;  the  pulse  is 
small,  hard  and  rapid  ;  the  breathing  is  shallow  and  thoracic. 
Shock  and  collaxjse  are  common.  With  the  fall  of  temperature, 
the  patient's  mind  may  become  clear.     Death  may  take  place  in 


TYPHOID  FEVER — ENTERIC  FEVER, 


41 


a  few  hours ;  but  more  commonly  the  temperature  again  rises 
and  the  symptoms  of  jjeriionitis  become  predominant,  death  oc- 
curring in  the  course  of  a  few  days. 

Fatal  perforation  may,  however,  occur  without  decided  symp- 
toms either  of  shock  or  of  peritonitis  ;  or  there  may  be  a  sudden 
fall  or  a  sudden  rise  of  temperature,  a  sudden  increase  in  the 
jiulse-rate  or  in  the  intensity  of  the  prostration,  or  there  may 
be  sudden  vomiting  ;  or  there  may  be  simply  persistent  and 
rebellious  tympanites,  with  comparatively  slight  abdominal  ten- 
derness and,  perhaps,  marked  depression  in  the  general  state  of 
the  patient.  While  perforation  is  usually  fatal,  recovery  has 
occurred  in  well-authenticated  instances. 

How  are  typhoid  fever  and  pyemia  to  be  differentiated  ? 

Pyemia  may  be  attended  with  typhoid  symptoms,  diarrhea  and 
cerebral  manifestations.     The  temperature  (Fig.  4),  however, 


Fig.  4. 


42° 
41° 
40° 
39° 
38° 
37° 


mill 
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Temperature-chart  of  a  case  of  pyemia.    (Wunderlicli.) 


pursues  a  different  course  from  that  of  typhoid  fever ;  it  is  irregu- 
lar and  presents  wide  variations  in  range,  often  declining  below 
the  normal.  The  morning  temperature  may  be  normal,  tliat  of 
noon  several  degrees  above  normal,  that  of  evening  lower  than 
that  of  noon.  There  may  be  great  and  sudden  changes  from 
day  to  da}''.     In  addition,  there  may  be  recurrent  chills  and 


42  ESSENTIALS   OF   DIAGNOSIS. 

sweats.  The  rose-rash,  the  diazo-reaction  and  the  Widal  reac- 
tion are  wanting.  The  colorless  blood-corpuscles,  and  especially 
the  polynuclear  leukocytes,  are  increased  in  number.  The 
detection  of  a  primary  focus  of  suppuration  and  the  results  of 
metastasis  point  to  the  cause  of  the  equivocal  symptoms. 

How  are  typhoid  fever  and  a  typhoid  condition  to  be  differ- 
entiated ? 
A  condition  of  asthenia  and  low  vitality  developing  in  the 
course  of  certain  febrile  conditions,  surgical  affections,  septice- 
mia and  pyemia,  possibly  attended  with  diarrhea,  is  to  be  dis- 
tinguished from  typhoid  fever  by  the  previous  history  :  on  the 
one  hand,  there  are  the  evidences  of  some  constitutional  or  local 
disease  ;  on  the  other,  epistaxis,  headache,  continuous  fever  of 
gradual  invasion.  The  age  of  the  patient  may  have  weight  : 
typhoid  fever  being  infrequent  after  thirty-five  and  rare  after 
fifty,  while  in  the  aged  many  diseases,  especially  pneumonia, 
commonly  assume  a  typhoid  type.  A  rose-rash,  the  diazo- 
reaction  and  the  Widal  reaction  are  all  significant  of  typhoid 
fever. 

How  are  typhoid  fever  and   yellow  fever  to  be  differen- 
tiated? 

Initial  headache  and  pains  in  the  loins  attend  both  typhoid 
fever  and  yellow  fever ;  but,  in  the  latter,  epistaxis  and  diarrhea 
are  wanting,  the  onset  is  abrupt  and  the  symptoms  remit  on 
the  second  or  third  day.  The  discoloration  of  the  skin  that 
gives  its  name  to  yellow  fever  is  wanting  in  typhoid.  Yellow 
fever  is  a  disease  of  hot  climates ;  typhoid  fever,  one  rather  of 
temperate  climates.  The  characteristic  facies  of  yellow  fever 
is  wanting  in  typhoid,  while  albuminuria  is  less  common  and 
the  slowing  of  the  pulse,  in  proportion  to  the  temperature,  is 
less  marked  in  the  latter  than  in  the  former.    - 

How  are  typhoid  fever  and  variola  to  be  differentiated  ? 

For  several  days  it  may  be  impossible  to  distinguish  typhoid 
fever  and  variola  from  one  another.  Both  present  headache  and 
pains  in  the  back.  Epistaxis  and  diarrhea  may  be  wanting  in 
typhoid  fever.     The  onset  of  variola,  however,  is  likely  to  be 


TYPHOID    FEVER — ENTERIC    FEVER.  43 

abrupt  ;  that  of  typhoid  fever  insidious  and  gradual.  On  the 
third  or  fourth  day,  there  appears  in  variola  a  characteristic 
eruption  ;  simultaneously,  the  temperature  declines.  The  erup- 
tion of  typhoid  fever  is  unlike  that  of  variola  and  rarely  appears 
before  the  fifth  day.  The  subsequent  course  of  the  two  diseases 
is  sufficiently  diverse  to  remove  any  possibility  of  confusion. 
The  presence  or  absence  of  vaccine  protection  and  the  existence 
of  other  cases  of  one  or  of  the  other  disease  may  have  some 
weight  in  the  early  diagnosis. 

How  may  one  avoid  confounding  pneumonia  with  typhoid 
fever  ? 
While  pneumonia  may  present  symptoms  of  a  typhoid  char- 
acter and  a  temperature-course  not  unlike  that  of  typhoid  fever, 
the  respiratory  frequency  is  out  of  all  proportion  to  the  pulse- 
I'ate,  while  careful  physical  examination  will  reveal  the  signs  of 
pulmonary  consolidation  (dulness  on  percussion,  bronchial 
breathing,  crepitant  rales,  increased  vocal  fremitus  and  vocal 
resonance)  and  perhaps  the  friction-sound  of  an  associated 
pleurisy.  Pleurisy,  however,  is  by  no  means  rare  early  in  the 
course  of  typhoid  fever.  The  appearance  of  rusty  sputum 
clinches  the  diagnosis  of  pneumonia.  It  must,  however,  be 
borne  in  mind  that  pneumonia  may  occur  as  a  complication  of 
typhoid  fever.  In  such  a  case,  the  association  must  be  recog- 
nized by  the  rose-rash,  the  splenic  enlargement,  the  diarrhea 
and  the  protracted  course  of  the  disease. 

How  are  typhoid  fever  and  trichiniasis  to  he  differentiated  ? 

Trichiniasis  may  present  many  of  the  manifestations  of 
typhoid  fever,  but  the  epistaxis,  the  severe  headache,  the  en- 
largement of  the  spleen,  the  characteristic  stools,  the  typical 
temperature-curve  and  the  rose-spots  are  usually  wanting.  The 
knowledge  that  there  is  such  a  condition  as  trichiniasis,  with 
inquiry  as  to  the  food  taken  and  the  detection  of  nodules  in 
the  painful  muscles,  ought  to  be  sufficient  to  prevent  mistake. 
The  increased  number  of  eosinophile  leukocytes  is  a  point 
strongly  in  favor  of  trichiniasis. 


44  ESSENTIALS   OF   DIAGNOSIS. 


Typhus  Fever. 

What  are  the  symptoms  of  typhus  fever? 

Typhus  fever,  also  called  famine-fever,  shipfever  and  jailfeier, 
is  an  acute,  infectious  disease  of  sudden  onset,  with  a  papular 
eruption  and  pronounced  nervous  symptoms,  usually  terminat- 
ing by  crisis  at  the  close  of  the  second  week.  It  is  highly  con- 
tagious and  develops  in  crowded  and  unwholesome  places, 
among  the  poor  and  wretched,  although  it  may  be  communi- 
cated to  any.  There  are  no  distinctive  lesions.  The  disease 
has  a  period  of  incubation  of  variable  duration — from  a  few  hours 
to  two  weeks,  during  which  the  patient  is  comparatively  com- 
fortable, or  there  may  be  a  brief  stage  of  preliminary  depression. 

With  the  onset  of  the  disease  there  are  general  malaise,  head- 
ache, perhaps  a  chill,  pains  in  the  back  and  a  heavily  coated 
tongue,  perhaps  with  nausea.  The  temperature  rises  to  between 
V)4P  and  106°  F.  ;  the  pulse  is  frequent,  at  first  full,  but  early 
becoming  feeble.  Stupor  soon  develops.  The  bowels  are 
usually  constipated.  The  expression  is  dull.  The  conjunctivoe 
are  injected.  The  pupils  are  usually  contracted.  The  face 
appears  livid.  A  musty  odor  is  manifest.  The  body  may  be 
covered  by  a  diffuse,  red  rash.  Between  the  fourth  and  the  sixth 
day  a  coarse,  papular  eruption  appears,  usually  on  the  trunk  and 
extremities,  exceptionally  on  the  face.  Intermingled  with  this 
are  many  petechial  spots.  For  two  or  three  days  new  papules 
appear,  to  recede  gradually  and  disappear. 

At  the  close  of  the  first  week  or  early  in  the  second,  low, 
muttering  delirium,  or  coma-vigil,  without  great  restlessness  or 
with  ceaseless  tossing,  muscular  twitching  and  jactitation, 
appears  ;  the  mental  depression  is  profound.  In  the  cerebral 
type  there  is  a  wild,  fighting  delirium,  with  intolerance  of  light 
and  illusions  of  sight  and  hearing.  Excitement  is  soon  suc- 
ceeded by  weakness  and  prostration,  perhaps  by  fatal  coma.  In 
some  cases  the  respiration  is  shallow,  irregular  and  noisy,  though 
no  change  in  the  lungs  can  be  detected.  The  heart-sounds  are 
feeble,  though  the  beat  may  be  excited.  Often,  there  develops 
an  endocardial  murmur,  due  to  the  depraved  state  of  the  blood. 


TYPHUS    FEVER.  45 

The  tongue  is  brown  and  cracked,  the  teeth  and  gums  covered 
with  sordes.  The  urine  is  scanty,  high-colored,  deficient  in 
chlorides  and  may  contain  albumin. 

In  cases  that  recover  the  temperature  gradually  subsides  at 
the  end  of  the  second  week,  a  decided  decline  taking  place  on 
the  fourteenth  or  sixteenth  day,  accompanied,  perhaps,  with 
profuse  perspiration,  diarrhea  or  a  copious  discharge  of  urine. 
Bclapses  are  rare.  An  attack  confers  subsequent  imnmnity. 
Pulmonary  complications  are  the  most  common.  Others  may  be 
meningitis,  phlebitis,  gangrene,  erj'sipelas,  parotiditis,  edema  of 
the  larynx.  During  the  last  stages,  or  after  convalescence, 
acute  tuberculosis  may  develop. 

How  are  typhoid  fever  and  typhus  fever  to  be  differentiated  ? 

Typhus  fever  is  contagious  ;  typhoid  is  not.  Typhus  is  the 
more  likely  to  be  epidemic.  Prodromata  are  more  common  and 
of  longer  duration  in  typhoid.  The  onset  is  acute  in  typhus. 
Insidious  in  typhoid.  Typhus  lasts  about  two  weeks  ;  typhoid 
not  less  than  three.  The  eruption  of  t3'phoid  consists  of  small 
rose-spots,  usually  confined  to  the  abdomen  and  cliest,  and  ap- 
pearing in  successive  crops  ;  that  of  typhus  is  coarse,  maculai 
and  petechial  and  of  more  extensive  distribution.  The  skin  is 
usually  moist  in  tj^phoid  ;  it  is  dry  in  typhus.  In  typhus,  the 
body  exhales  a  characteristic  musty  odor.  The  bowels  are 
often  loose  in  typhoid  fever  ;  they  are  usually  constipated  in 
typhus.  Kervous  prostration  is  the  more  profound  in  typhus. 
The  course  of  the  temperature  is  different  in  each.  Epistaxis  is 
common  in  typhoid ;  uncommon  in  typhus.  The  Widal  reac- 
tion and  the  diazo-reaction  belong  to  typhoid  and  not  to  typhus 
fever.  In  typhoid  fever,  one  finds  on  post-mortem  examination 
intestinal  ulceration  and  enlargement  of  the  spleen  and  of  the 
mesenteric  glands ;  in  typhus,  no  constant  lesions ;  though  the 
spleen  is  likely  to  be  diffluent.  Typhoid  fever  and  typhus  ^^vei 
may,  though  rarely,  coexist  in  the  same  patient. 

How  are  variola  and  typhus  fever  to  be  differentiated  ? 

Both  variola  and  typhus  fever  are  in  a  high  degree  contagious. 
Should  both  be  simultaneously  epidemic,  the  diagnosis  may  be 
difficult  during  the  first  few  days  of  the  attack.     Tlie  eruption 


46  ESSENTIALS    OF    DIAGNOSIS. 

of  variola,  however,  appears  from  twenty-four  to  thirty-six 
hours  earlier  than  that  of  typhus.  The  former  is  usually  situated 
on  the  face,  as  well  as  on  the  trunk,  and  passes  successively 
through  the  stages  of  papule,  vesicle  and  pustule,  the  pustules 
rupturing  and  leaving  cicatrices.  The  eruptionof  typhus  fever 
rarely  or  never  appears  on  the  face  ;  it  remains  largely  papu- 
lar, though  in  part  it  becomes  petechial.  In  typhus  fever,  the 
temperature  becomes  high  at  the  onset  and  continues  high  ;  in 
variola,  the  temperature  declines  with  the  "appearance  of  the 
eruption.  Vaccination  commonly  protects  against  variola ;  it 
affords  no  protection  from  typhus  fever.  Finally,  typhus  is  a 
disease  of  about  two  weeks'  duration  ;  variola,  of  quite  three. 

Cerebro-spinal  Fever— Epidemic  Cerebro-spinal 

Meningitis. 

What  are  the  clinical  features  of  cerebro-spinal  fever  ? 

Cerebrospinal  fever  or  epidemic  cerebro-spinal  memingitis  is  an 
acute  infectious  disease,  dependent  upon  the  activity  of  the 
meningococcus  or  diplococcus  intracellularis  meningitidis, 
which  is  present  in  the  blood,  in  the  exudate,  and  in  fluid 
obtained  by  lumbar  puncture.  Epidemics  occur  most  com- 
monly in  winter  and  spring.  Overcrowding,  filth  and  other 
unsanitary  conditions  are  predisposing  influences.  The  disease 
varies  much  in  its  clinical  manifestations,  but  it  is  usually 
characterized  by  decided  disturbances  of  the  cerebro-spinal  func- 
tions. In  some  cases  cerebral,  in  others  spinal  symptoms  pre- 
dominate. Not  infrequently,  respiratory  phenomena  or  blood- 
changes  assume  great  prominence.  A  characteristic  eruption 
is  usually  a  marked  feature. 

The  attack  ma}-  develop  gradually,  but  more  often  it  sets  in 
suddenly,  with  a  rigor  followed  by  fever ;  malaise ;  nausea ; 
great  thirst  and  vomiting,  often  with  a  clean  tongue  and  no 
gastric  derangement ;  vertigo ;  excruciating  headache,  remit- 
ting, but  never  entirely  ceasing,  and  attended  with  paroxysmal 
exacerbations  ;  rigidity  of  the  head  and  neck,  sometimes  passing 
into  opisthotonos  ;  muscular  twitchings  or  convulsions  ;  dry- 


CEREBRO-SPINAL    FEVER.  47 

ness  of  the  skin,  with  hyperesthesia  and  paresthesia.  There 
may  also  be  photophobia  and  tinnitus  aurium.  Prostration 
soon  becomes  profound,  though  restlessness  may  continue.  De- 
lirium may  set  in  and  be  followed  by  stupor  and  coma.  The 
expression  is  anxious.  The  puhe  is  rapid  and  extremely  irregu- 
lar. The  temperature  fluctuates  between  wide  limits.  Hyper- 
pyrexia is  not  rare.  It  may  develop  suddenly  and  persist  until 
death.  The  temperature  may  continue  to  rise  after  death.  A 
sudden  fall  of  temperature  may  usher  in  collapse  and  death.  A 
gradual  fall  of  temperature  precedes  recovery.  When  the  thigh 
is  placed  at  a  right  angle  with  the  trunk  the  leg  can  be  only 
partially  flexed.  The  action  of  the  sphincters  is  often  deranged, 
so  that  there  may  be  incontinence  of  urine  or  feces,  or  reten- 
tion of  urine,  or  constipation.  As  a  rule,  retention  is  an  early, 
incontinence  a  late,  symptom.  The  urine  is  often  albuminous 
and  contains  an  excess  of  urates.  The  number  of  colorless 
blood-corpuscles  is  increased,  particularly  the  polynuclear  leuko- 
cytes. 

Between  the  first  and  the  third  day,  purpuric  spots,  or  an  ery- 
thematous eruption  that  quickly  becomes  petechial,  may  appear 
upon  the  trunk  and  extremities.  The  disease  is  sometimes 
called  "spotted  fever,"  from  the  character  of  this  eruption. 
Between  the  third  and  the  sixth  day,  herpetic  vesicles  may  ap- 
pear on  the  face  about  the  lips. 

In  the  further  progress  of  the  case,  the  pmpih^  at  first  con- 
tracted, become  dilated  ;  paralysis  and  anesthesia  of  irregular 
distribution  appear  ;  disturbances  of  sight  and  hearing,  perhaps 
also  blindness  and  deafness  develop.  The  respiration  may  be 
profoundly  disturbed.  As  death  approaches  there  is  difficulty 
in  swallowing  and  the  breathing  may  assume  the  Cheyne-Stokes 
type.  Short  remissions  in  the  general  severity  or  in  individual 
symptoms  may  occur,  to  be  followed  by  renewed  exacerbations. 
The  duration  of  the  disease  is  variable.  The  fastigium  is  com- 
monly reached  on  the  sixth  day.  In  protracted  cases,  profound 
emaciation  occurs.  Death  may  take  place  early  or  late,  in  coma, 
by  exhaustion,  or  by  apnea.  If  recovery  ensues j  convalescence 
is  tardy,  and  sometimes  protracted,  while  permanent  loss  of 
special  senses  is  common.    Pneumonia  is  a  common,  arthritis 


48  ESSENTIALS    OF    DIAGNOSIS. 

a  rare,  complication.  Palsies,  headache  and  epileptiform  convul- 
sions may  be  additional  sequelce. 

In  addition  to  the  ordinary  type  of  epidemic  cerebro-spinal 
meningitis,  there  may  he  fulminant  cases  (death  occurring  within 
twelve  hours),  mild  or  abortive  cases  and  protracted  or  typhoid 
cases.     Sporadic  cases  are  rare. 

Instances  of  contagion  (direct  transference  from  the  sick  to 
the  well)  and  of  portagion  (conveyance  by  the  person  or  be- 
longings of  those  that  have  been  in  contact  with  tlie  sick)  of 
cerebro-spinal  fever  appear  to  have  been  authenticated,  but  are 
extremely  uncommon. 

How  are  cerebro-spinal  fever  and  tetanus  to  be  differentiated? 

Cerebro-spinal  fever  appears  in  epidemics,  while  tetanus 
usually  occurs  sporadically,  as  a  result  of  the  infection  of  a 
wound  by  soil.  Trismus,  an  early  symptom  of  tetanus,  is  the  less 
common  in  cerebro-spinal  fever.  Opisthotonos,  general  rigidity 
and  spasm  are  more  marked  in  tetanus  than  in  cerebro-spinal 
fever.  The  presence  of  the  meningococcus  in  the  fluid  obtained 
by  lumbar  puncture  is  distinctive  of  the  latter.  Recovery  from 
tetanus  is  exceptional.  Death  is  not  the  invariable  termination 
of  cerebro-spinal  fever. 

Tetanus  is  wanting  in  the  palsies,  the  eruption,  the  leuko- 
cytosis, the  derangement  of  intellection  and  sensation  and  the 
febrile  symptoms  of  cerebro-spinal  fever,  though  toward  the 
fatal  termination  the  temperature  may  rise  inordinately  high. 

How  are  cerebro-spinal  fever  and  typhus  fever  to  be  differ- 
entiated ? 
While  both  cerebro-spinal  fever  and  typhus  fever  occur  in 
epidemics,  and  both  may  be  sudden  in  onset  and  attended  with 
profound  nervous  phenomena  and  petechial  eruption,  cerebro- 
spinal fever  has  not  the  dusky,  stupid  facies  of  typhus,  while 
the  herpes  of  the  face,  the  retraction  of  the  head,  the  fixed 
spinal  pain,  the  muscular  rigidity  and  the  heightened  sensi- 
bility of  cerebro-spinal  fever  are  not  observed  in  typhus ;  nor  is 
typhus,  as  a  rule,  accompanied  with  the  great  impairment  of  spe- 
cial senses  or  followed  by  the  paralytic  sequelse  of  cerebro-spinal 
fever.     The  general  course  of  the  two  diseases,  the  fever  and 


CEREBRO-SPINAL    FEVER.  49 

the  eruption  may  be  discriminated  on  careful  observation.    The 
greatest  difficulty  occurs  in  cases  of  malignant  cerebral  typhus. 

How  are  cerebro-spinal  fever  and  torticollis  to  be  differen- 
tiated? 

The  muscular  contraction  that  gives  rise  to  torticollis  is  usually 
unilateral  and  limited,  while  in  cerebro-spinal  fever  the  con- 
traction is  symmetrical  and  not  confined  to  the  muscles  of  the 
head  and  neck.  The  symptoms  of  an  acute,  febrile  disease,  with 
disturbances  of  the  sensorium  and  paralytic  concomitants  and 
sequelae,  are  not  present  in  torticollis,  but  are  characteristic  of 
cerebro-spinal  fever.  Even  mild  cases  of  cerebro-spinal  fever, 
lacking  the  characteristic  febrile  course  and  without  eruption, 
will  present  severe  headache. 

What  are  the  distinctions  between  cerebro-spinal  fever  and 
smallpox  ? 
Headache,  vertigo,  nausea,  vomiting,  pain  in  the  back  and 
fever  attend  both  cerebro-spinal  fever  and  smallpox ;  but  re- 
traction of  the  head,  muscular  rigidity  and  paralysis,  hyper- 
esthesia and  anesthesia  are  wanting  in  smallpox,  and  the  pecu- 
liar temperature-record  and  the  characteristic  eruption  of  small- 
pox are  not  seen  in  cerebro-spinal  fever. 

What  are  the  distinctions  between  cerebro-spinal  fever  and 
yellow  fever  ? 

Yellow  fever  is  especially  a  disease  of  hot  climates ;  when 
found  elsewhere  its  importation  may  be  traced.  If  cerebro-spinal 
fever  display  any  susceptibility  to  climatic  conditions,  it  is  most 
common  in  temperate  zones.  Characteristic  symptoms  of  motor 
and  sensory  derangement,  observed  in  the  course  of  cerebro- 
spinal fever,  are  wanting  in  yellow  fever,  which  is  a  disease  of 
brief  duration,  in  contrast  to  cerebro-spinal  fever,  the  duration 
of  which  may  be  protracted.  Petechial  and  herpetic  eruptions 
appear  during  the  progress  of  cerebro-spinal  fever,  while  yellow 
fever  is  characterized  by  a  saffron-yellow  color  of  the  skin.  The 
black  vomit  often  seen  in  yellow  fever  is  entirely  wanting  in 
cerebro-spinal  fever.  Although  remissions  in  the  intensity  of 
special  symptoms  may  occur  in  the  course  of  cerebro-spinal 
fever,  the  characteristic  "  lull"  of  yellow  fever  is  absent. 
4 


50  ESSENTIALS    OF    DIAGNOSIS. 

How  are  cerebro-spinal  fever  and  typhoid  fever  to  be  differen- 
tiated ? 

In  cerebro-spinal  fever,  the  onset  is  usually  abrupt  ;  in 
typhoid  it  is  insidious.  In  typhoid  fever  the  temperature  pur- 
sues a  typical  course  ;  in  cerebro-spinal  fever  there  is  no  regu- 
larity. The  eruption  of  cerebro-spinal  fever  is  petechial  or 
herpetic  and  appears  early — before  the  fourth  day  ;  that  of 
typhoid  is  roseolous  and  appears  not  earlier  than  the  fifth  or 
sixth  day.  Constipation  is  the  rule  in  cerebro-spinal  fever  ; 
diarrhea  often  attends  typhoid.  Nausea  and  vomiting  occur  in 
cerebro-spinal  fever,  but  not  usually  in  typhoid.  The  retraction 
of  the  head,  the  paresthesise  and  the  paralyses  of  cerebro-spinal 
fever  are  all  wanting  in  typhoid  fever.  The  headache  is  more 
intense  in  cerebro-spinal  than  in  typhoid  fever ;  in  the  latter  it 
disappears  when  delirium  sets  in;  in  the  former,  delirium  a.nd 
headache  coexist.  Leukocytosis  attends  cerebro-spinal  fever, 
not  uncomplicated  typhoid.  Lumbar  puncture  may  disclose 
the  presence  in  the  arachnoid  fluid  of  the  specific  diplococci 
of  the  former.  The  knowledge  of  an  epidemic  assists  in  the 
diagnosis.  The  discovery  ophthahnoscopically  of  recent  papil- 
litis (choked  disc)  or  optic  neuritis  would  be  diagnostic  of  cere- 
bro-spinal meningitis  in  contradistinction  from  uncomplicated 
typhoid  fever.  In  rare  cases,  typhoid  fever  is  complicated  by 
meningitis. 

Asiatic  Cholera, 

What  are  the  symptoms  of  Asiatic  cholera  ? 

Asiatic  cholera,  also  called  cholera  infectiosa,  is  an  acute,  infec- 
tious disease,  having  its  home  in  tropical  climates  and  occurring 
in  epidemics.  It  is  dependent  upon  a  specific  organism,  which 
is  found  in  the  alvine  discharges  of  the  patient  and  is  principally 
transmitted  by  means  of  milk  and  drinking-water. 

The  disease  has  a  period  of  incuhation  of  from  half  a  day  to 
three  or  four  days.  It  may  set  in  suddenly,  with  a  chill,  but 
more  usually  the  attack  proper  is  preceded  by  a  moderate  diar- 
rhea, to  which  the  name  cholerine  has  been  given.     This  con- 


ASIATIC   CHOLERA.  51 

stitutes  the  first  ov  premomtory  stage.  The  course  of  the  disease 
may  be  arrested  at  this  stage. 

In  the  s€C07id  stage  [stage  of  sjMsm^  or  stage  of  serous  diarrhea), 
there  occur  violent  cramps  in  the  abdomen  and  legs,  and  the 
intestinal  flux  increases  in  severity.     There  is  often  obstinate 

Fig.  5. 

■mm  %i' 

Comma-bacillus  of  cholera.    (Vierordt.) 

vomiting.  The  patient  complains  of  thirst,  is  restless  and  anxi- 
ous ;  prostration  is  marked  ;  the  pulse  is  weak  and  thready  ;  the 
skin  is  cold  and  shrunken  ;  the  eyeballs  are  sunken.  The  tem- 
perature, taken  in  the  rectum  or  with  a  thermometer  carefully 
applied  and  allowed  to  remain  at  least  ten  minutes  in  the  axilla, 
will  be  found  to  be  elevated.  The  stools  are  almost  liquid  and 
colorless  and  contain  large  quantities  of  epithelium,  constituting 
the  so-called  "  rice-water"  discharges,  in  which  the  comma-hacil- 
lus  of  Koch  (Fig.  5)  is  to  be  found. 

Soon,  a  third  or  algid  stage,  or  stage  of  collapse,  sets  in.  The  ciixu- 
lation  fails,  and  there  is  marked  depression  of  the  vital  powers  ; 
the  respiration  is  shallow  and  accelerated  ;  the  sTcin  becomes  as 
cold  as  marble  ;  the  breath  may  be  chilling ;  the  voice  is  lost. 
Suppression  of  urine  often  occurs.  The  urine  that  is  secreted  is 
albuminous  and  contains  casts. 

In  this  condition  of  collapse  the  patient  may  die,  or  he  may- 
enter  u]Don  a  fourth  stage,  or  stage  of  reaction,  convalescence  set- 
ting in  or  a  low,  typhoid  condition  developing,  with  fever  and 
delirium  and  possibly  with  suppression  of  urine.  This  stage  may 
terminate  in  death  or  in  convalescence.  Convalescence  may  be 
complicated  by  ulceration  of  the  cornea  and  by  parotiditis. 


52  ESSENTIALS    OP    DIAGNOSIS. 

How  are  cholera  nostras  and  cholera  Asiatica  to  be  differ- 
entiated? 

Cholera  nostras  occurs  sporadically ;  cholera  Asiatica,  endem- 
ically  or  epidemically,  and,  in  Europe  and  America,  by  importa- 
tion. Asiatic  cholera  is  by  far  the  ,a:raver  affection  ;  the  stools 
present  a  characteristic  "  rice-water  "  appearance,  and  in  them 
a  specific  bacillus  is  to  be  found.  If  an  apparently  similar 
bacillus  be  found  in  the  stools  of  cholera  nostras,  its  morphology 
and  culture  will  prove  it  to  be  different. 

How  is  arsenical  poisoning  to  be  distinguished  from  cholera? 

Poisoning  by  arsenic  occasions  vomiting,  cramps  in  the  abdo- 
men and  legs,  and  diarrhea  with  stools  of  a  "  rice-water"  char- 
acter. Local  evidences  of  the  ingestion  of  arsenic  may  be 
present  in  the  mouth ;  vomiting  precedes  diarrhea  ;  the  stools 
are  bloody  and  do  not  contain  the  specific  comma-bacilli. 


Relapsing  Fever. 

What  are  the  distinguishing  features  of  relapsing  fever  ? 

Relapsing  fever  is  a  specific,  infectious  disease  of  intermittent 
type,  dependent  upon  the  presence  in  the  blood  of  a  specific 

Fig.   6. 


<$fPoo9$ 


Spirochetal  of  relapsing  fever.    (V.  Jaksch.) 

organism — the  spirocheta  Obermeierii.    (Fig.  6.)     Transmission  is 
thought  to  take  place  through  the  intermediation  of  mosqui- 


RELAPSING    FEVER.  53 

toes.  The  disease  has  commonly  prevailed  amid  unfavorable 
hygienic  conditions. 

The  growth  and  development  of  the  parasite  give  rise  to  the 
periodic  paroxysms  that  characterize  the  disease  and  give  it 
its  name.  After  a  period  of  incubation^  varying  from  several 
hours  to  two  weeks,  the  disease  sets  in  suddenly  with  a  chill, 
followed  by  fever,  with  decided  elevation  of  temperature^  mus- 
cular pains,  vertigo,  headache,  nausea  and  vomiting.  The 
spleen  is  enlarged.     Often  there  is  jaundice. 

In  the  course  of  from  five  to  seven  days  the  attack  abates 
with  the  suddenness  with  which  it  set  in,  the  temperature  fall- 
ing to  the  normal  and  profuse  diaphoresis  occurring, 

For  about  a  week  the  patient  is  free  from  symptoms.  At  the 
end  of  this  time,  the  paroxysm  is  repeated,  to  again  subside ; 
and  this  may  happen  a  number  of  times. 

Convalescence  is  tardy  and  protracted.  During  the  paroxysms, 
spirochete  in  large  numbers  may  be  found  in  the  blood.  They 
are  not  to  be  found  during  the  intermissions. 

How  is  relapsing  fever  to  be  diagnosticated  from  typhoid  fever  ? 

In  typhoid  fever,  both  onset  and  subsidence  are  gradual ;  in 
relapsing  fever,  they  are  sudden.  The  former  is  a  continued 
fever ;  the  latter  intermittent  and  periodic.  Eelapsing  fever 
does  not  present  the  rose-rash  of  typhoid  fever.  Jaundice, 
often  present  in  relapsing  fever,  is  rare  in  typhoid  fever.  Spi- 
rochetse  are  not  found  in  the  blood  in  typhoid  fever,  while  the 
Widal  reaction  and  diazo-reaction  are  distinctive  of  this  disease. 

How  does  relapsing  fever  differ  from  typhus  fever  ? 

The  course  of  relapsing  fever  is  interrupted  by  intermissions, 
giving  rise  to  a  disease  of  periodic  type  ;  typhus  is  a  continued 
fever. 

The  marked  nervous  symptoms,  as  well  as  the  exanthem,  of 
typhus  are  wanting  in  relapsing  fever. 

Spirochetse  are  found  in  the  blood  only  in  relapsing  fever. 

Upon  what  does  the  differential  diagnosis  between  relapsing 
fever  and  yellow  fever  depend  ? 

Yellow  fever  is  a  disease  of  not  more  than  three  stages  ;  there 


54  ESSENTIALS    OF    DIAGNOSIS. 

may  be  more  or  less  in  relapsing  fever.  The  primary  acute 
stage,  as  well  as  the  period  of  intermission  or  remission,  is  longer 
in  relapsing  fever  than  in  yellow  fever.  Vomiiing  occurs  late 
in  yellow  fever,  early,  if  at  all,  in  relapsing  fever.  Vertigo  is 
a  more  marked  symptom  in  relapsing  than  in  yellow  fever.  The 
occurrence  of  one  or  the  other  in  an  epidemic  might  afford  a 
clue  in  diagnosis.  Spirochetae  are  present  in  the  blood  in  re- 
lapsing fever  ;  they  are  not  found  in  yellow  fever. 


Malarial  Diseases. 

What  are  the  characteristics  of  malarial  disease  ? 

The  group  of  diseases  known  as  malarial  is  characterized  by 
paroxysmal  periodicity,  enlargement  of  the  spleen  and  liver, 
melanemia  and  the  presence  in  the  blood,  free  or  within  the  red 
corpuscles,  of  parasites  that  exert  a  deleterious  influence  upon 
the  red  cells.  (Fig.  7.)  Tertian,  quotidian  and  estivo-autumnal 
parasites  have  been  described.  The  parasites  of  tertian  and 
quartan  fever  are  ameboid  bodies  that  enter  the  red  blood- 
corpuscles,  at  whose  expense  they  develop.  They  are  at  first 
unpigmented,  but  in  the  course  of  development  pigment-gran- 
ules appear.  The  parasites  complete  their  cycle  of  develop- 
ment and  break  up  into  spores  at  the  end  of  forty-eight  and 
seventy-two  hours  respectively.  The  occurrence  of  sporulation 
coincides  wdth,  or  rather,  precedes,  the  appearance  of  the  par- 
oxysm. The  estivo-autumnal  parasite  appears  to  be  much 
more  irregular  in  development.  Sometimes  the  parasites  as- 
sume a  crescentic  shape.  More  than  one  generation  of  the 
same  parasite,  or  more  than  a  single  variety  of  parasite,  may 
be  present,  and  give  rise  to  corresponding  variations  in  the 
type  of  fever.  It  is  believed  that  the  disease  is  conveyed 
through  the  agency  of  mosquitoes. 

During  the  parox3^sm,  the  urine  is  said  to  be  irritant,  the 
proportion  of  both  water  and  solids  being  increased.  It  often 
contains  albumin,  and  there  is  sometimes  a  complicating 
nephritis. 


MALARIAL    DISEASES. 


55 


Malarial  diseases  prevail  principally  in  the  lowlands  of  warm 
climates,  with  marshy  soils. 

Fig.  7. 


Organisms  of  malaria — intracorpiiscular. 
Fig.  8. 


QQ)         Q 


Organisms  of  malaria — extracorpuseular.    (MacS.) 


What  are  the  varieties  of  malarial  fever  ? 

Malarial  fevers  are  said  to  be  intermittent  when  between  two 
paroxysms  there  intervenes  a  period  of  freedom  from  symp- 
toms, with  a  restoration  of  the  temperature  to  the  normal ; 
remittent,  when  between  two  paroxysms  the  symptoms  moder- 
ate and  the  temperature  falls  (but  not  to  the  normal  level). 

When  the  paroxysm  is  repeated  daily,  the  fever  is  designated 
quotidian;  if  repeated  on  alternate  days,  tertian;  if  with  an 
interval  of  two  days,  quartan.  If  two  paroxysms  occur  daily, 
the  fever  is  called  a  duplicated  quotidian.      There  may  be  a 


56  ESSENTIALS    OF    DIAGNOSIS. 

double  tertian,  in  which  occur  daily  paroxysms,  of  wliich  only 
those  of  alternate  days  are  alike  ;  a  double  quartern,  and  other 
combinations.  When  the  paroxysms  succeed  one  another  so 
closely  that  the  cold  stage  of  one  begins  before  the  sweating 
stage  of  its  predecessor  ends,  the  fever  is  called  subintrant. 

Morphologic  and  biologic  differences  among  the  organisms 
present  in  the  various  types  of  malarial  fever  have  been  recorded. 

What  are  the  features  of  a  malarial  paroxysm  ? 

A  typical  malarial  paroxysm  consists  of  a  cold  stage,  a  hot  stage 
and  a  sweating  stage.  The  disease  is  therefore  called  "  chills  and 
fever."     It  is  also  known  as  ague. 

What  are  the  characteristics  of  each  stage  ? 

The  cold  stage  or  chill  sets  in  with  malaise,  nausea,  vertigo, 
shivering ;  as  the  rigor  becomes  more  pronounced,  the  patient 
may  be  severely  shaken  ;  his  teeth  chatter  ;  the  skin  is  cold  and 
rough  ;  the  breathing  is  shallow  and  hurried  ;  the  pulse  is  small 
and  rapid  ;  the  temperature  of  internal  parts,  however,  is  febrile. 

Gradually,  the  feeling  of  coldness  subsides  and  gives  way  to  a 
sense  of  warmth,  the  temperature  of  the  rectum  or  of  the  mouth 
continuing  to  rise  ;  the  surface  of  the  body  becomes  flushed  and 
the  eyes  are  brilliant.  The  patient  has  now  subjective  sensa- 
tions of  fever.  After  the  lapse  of  a  variable  time,  a  more  or  less 
copious  perspiration  sets  in,  with  a  decline  in  the  temperature 
and  an  amelioration  or  disappearance  of  the  symptoms.  The 
paroxysm  is  at  an  end. 

What  are  the  clinical  features  of  malarial  intermittent  fever  ? 

In  intermittent  fever,  as  the  name  indicates,  there  is  in  the 
interval  between  two  paroxysms  a  complete  intermission  of  the 
symptoms,  the  temperature  becoming  normal  or  subnormal. 

The  cold  stage  lasts  from  fifteen  minutes  to  an  hour,  the  hot 
stage  and  the  srceating  stage,  respectively,  a  varying  number  of 
hours.  The  beginning  of  each  successive  paroxysm  anticipates 
in  time  of  the  clock  that  of  the  preceding  paroxysm.  The 
spleen  is  enlarged;   herpes  is  common. 

Untreated,  the  paroxysms  of  intermittent  fever  lose  their 
regularity. 

The  disease  may  gradually  and  spontaneously  subside,  or  the 


MALARIAL    DISEASES. 


57 


paroxysms  may  become  remittent  or  pass   into  the  malarial 
cachexia. 

After  apparent  recovery,  a  tendency  to  a  return  of  the  parox- 
ysms on  the  fifth,  seventh,  ninth  or  fourteenth  day  is  sometimes 
observed. 


Ficx.  9. 


Fig.  10. 


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■  !■■■■■■■■■ 

■  ilH.IHBBBSB 

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■QiHiiBiiggBg 

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■iiiBiiHiiiBsr'^ 

■  niBIIBDIHaH 

■  ■■■!■■■■■■■ 

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■NHIIBHI^i 

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■iir«iiiiiBBB.« 

IBiiiHiiin<BSB'i! 
BiiwiBnBB9£! 
■■■■■iiviiiySi 
■■■BWBt'A'liai 


Temperature-chart  of  quotidian 
intermittent  fever.  (Wunder- 
lich.) 


■  ■■■■  ■■BBgBg^g 

■  BBBB.'BBBBBSBS 

■  ■■■■'■Mi— ail 

■.■■■■iBBMMBBBBB 
■(■■■■(■^■■BIBB 


II 

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:iiB:isKi:a 

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■niBBIHHIIBHI' 

■  MI^HIHIHIII 
IIB^BBIIMHil 

MML^iBkAVaiMKIiBI 


liVil 

nil 


Temperature-chart  of  tertian 
intermittent  fever.  (TVun- 
derlich.) 


What  are  the  clinical  features  of  malarial  remittent  fever  ? 

Remittent  fever  represents  a  more  profound  degree  of  intoxi- 
cation than  does  intermittent  fever. 

The  chill  is  usually  severe  and  protracted.  In  addition,  there 
is  gastric  irritability,  perhaps  vomiting,  sometimes  jaundice. 
The  temperature  attains  a  high  degree.  The  Jwt  stage  may  last 
for  from  six  to  eighteen  hours  and  is  followed  by  profuse  perspi- 
ration. 

In  the  interval  between  two  paroxysms,  the  symptoms  moder- 
ate and  the  temperature  declines,  but  does  not  reach  the  nor- 
mal. 

After  the  occurrence  of  several  paroxysms,  the  chill  may  be 
wanting  ;  or  there  may  be  but  one— the  initial  chill.  Without 
medicinal  intervention,  the  remissions  may  gradually  become 
less  decided  and  a  typhoid  condition  may  develop. 


58  ESSENTIALS    OF    DIAGNOSIS. 

What  are  the  symptoms  of  hemorrhagic  malarial  fever? 

Hcmorrhayic  'Dialarial  fever  is  a  grave  form  of  malarial  intoxi- 
cation in  which  the  height  of  the  paroxysm  is  marked  by  head- 
ache, severe  pain  in  the  back,  nausea,  vomiting,  decided  jaun- 
dice and  hemorrhages  from  various  mucous  surfaces,  particularly 
from  the  kidneys. 

What  is  pernicious  malarial  fever  ? 

In  certain  localities  in  which  the  malarial  organisms  are  ex- 
ceedingly numerous  or  virulent,  the  attack  manifests  a  per?i{doifS 
tendency.  The  clinical  picture  depends  upon  the  system  that 
bears  the  brunt  of  the  disease.  There  may  thus  be  a  cerebral 
foi^m^  characterized  either  by  delirium  and  excitement  or  by 
coma  and  depression  ;  or  there  may  be  a  thoracic  form^  in  which 
the  respiration  is  accelerated,  and  there  is  an  urgent  sense  of 
the  need  of  air ;  or  there  may  be  a  gastro-intestinal  variety,  at- 
tended with  nausea,  vomiting,  jaundice  and  diarrhea ;  or  there 
may  be  an  asthenic  or  an  algid  variety,  in  which  there  is  a  condi- 
tion of  marked  debility  and  a  striking  coldness  of  the  surface 
and  of  the  breath.  Pernicious  malarial  fever  usually  manifests 
its  character  only  after  a  preliminary  paroxysm  of  apparently 
ordinary  intermittent  or  remittent  fever.  Unless  promptly  and 
vigorously  treated,  it  is  likely  to  be  fatal. 

What  are  the  symptoms  of  the  malarial  cachexia? 

After  protracted  residence  in  a  malarious  district  or  following 
untreated  or  rebellious  intermittent  or  remittent  fever,  there 
may  occur  irregular  chilly  sensations,  with  some  tendency  to 
periodicity,  an  occasional  sense  of  feverishness,  headache,  men- 
tal torpor,  drowsiness,  a  sallow  complexion,  constipation  or 
diarrhea,  impaired  appetite,  enlargement  of  the  spleen  and 
liver — a  complex  of  symptoms  that  may  not  yield  to  medicinal 
treatment,  but  which  improves  on'  removal  to  a  non-malarious 
climate. 

What  is  meant  by  "Dumb  Ague?" 

There  is  a  variety  of  irregular  manifestations  of  malarial  or 
paludal  poisoning,  sometimes  acute,  but  more  frequently  sub- 
acute or  chronic,  which  do  not  at  any  time  present  the  classical 
picture  of  chill,   fever  and  sweat.      These  attacks  of  "  dumb 


MALARIAL    DISEASES.  59 

ague,"  "masked  malaria,"  "larval  paludism,"  as  they  are 
variously  called,  comprise  chilly  sensations,  irregular  fever,  or 
tiushes,  or  subjective  sensations  of  heat,  joint-pains  and  muscle- 
pains,  headache  and  neuralgias  of  various  kinds,  cough,  with  or 
without  bronchial  or  laryngeal  signs,  gastric  and  other  visceral 
disturbances,  sometimes  taking  the  form  of  crises ;  in  severe  or 
protracted  cases,,  anemia,  anasarca  and  albuminuria,  hematu- 
ria and  hemoglobinuria  have  been  observed.  A  common  va- 
riety is  the  so-called  "brow-ague,"  a  form  of  frontal  headache 
frequently  associated  with  tenderness  of  the  nerves  at  the  supra- 
orbital and  infra-orbital  foramina  and  sometimes  with  an  in- 
tensely painful  sensation  of  pressure  or  constriction  referred  to 
the  nasal  bones  ;  the  manifestations  usually  exhibiting  an  irregu- 
lar periodicity.  Appearing  in  the  morning  and  disappearing  at 
night,  or  when  aggravated  by  sunlight,  it  is  called  "sun-pain." 
Enlargement  of  the  spleen  is  sometimes  demonstrable.  A 
careful  study  of  the  phenomena  in  these  cases  will  usually  elicit 
some  periodicity  in  their  recurrence,  or  while  the  prominent 
symptoms,  gastric  or  neuralgic,  or  whatever  they  may  be,  may 
not  be  periodic,  careful  temperature-observations  will  show  an 
unsuspected  periodic  rise.  Sometimes,  if  quinine  be  adminis- 
tered for  a  short  time,  and  then  withheld,  a  distinct  periodicity 
in  the  symptoms  will  be  developed  upon  withdrawal  of  the  drug. 
The  discovery  of  characteristic  plasmodia  in  the  blood  would 
establish  the  diagnosis.  The  organisms  are  usually  compara- 
tively few  in  number  and  of  the  crescentic  or  siclcle-shaped  variety. 
In  some  patients  there  is  a  tendency  to  annual  recurrence  of 
critical  manifestations. 

What  is  meant  by  Ague-cake  ? 

The  enlargement  of  the  spleen  in  a  case  of  chronic  malaria 
or  of  malarial  cachexia  is  sometimes  quite  manifest  to  ordinary 
inspection.  When  not  so  readily  manifest  to  sight,  it  may  easily 
be  detected  by  palpation.  Its  connection  with  malaria  being 
well  known,  the  enlarged  spleen  has  in  vulgar  parlance  acquired 
the  name  of  ague-cake. 

What  are  the  distinctions  between  malarial  fever  and  the  fever 
of  suppuration  or  of  septic  infection  ? 
Suppuration  and  septic  infection  usually  give  rise  to  fever  of 


60  ESSENTIALS    OF    DIAGNOSIS. 

a  remittent  or  intermittent  type.  When  an  obvious  cause  exists, 
the  recognition  of  the  nature  of  the  fever  is  easy.  AVhen,  how- 
ever, the  fever  is  induced  by  deep-seated  suppuration,  as  when 
abscesses  form  or  in  case  of  pulmonary  tuberculosis  or  of  occlu- 
sion of  the  hepatic  or  of  the  common  bile-duct,  the  connection 
may  be  obscure.  The  distinguishing  features,  however,  are  that 
the  symptoms  of  suppurative  or  of  septic  fever  are  rarely  of 
regular  periodicity  or  typical  in  course  ;  that  they  are  attended 
with  leukocytosis ;  that  they  are  often  uninfluenced  by  the  ad- 
ministration of  quinine,  which  acts  specifically  in  the  malarial 
diseases;  and  that  the  hematozoa  characteristic  of  malarial 
fever  are  wanting. 

With  what  conditions  may  pernicious  malarial  fever  be  con- 
founded ? 

The  gastro-intestinal  type  of  the  disease  may  simulate  ordinary 
gastro-intestinal  catarrh,  but  the  one  is  a  grave  condition,  while 
the  other  is  not ;  the  one  is  febrile  the  other  afebrile ;  the  one 
submits  to  treatment  by  quinine,  while  the  other  does  not ;  in 
the  one  the  blood  contains  characteristic  hematozoa  and  blood- 
pigment,  while  in  the  other  it  does  not;  in  the  one  the  spleen 
is  enlarged,  in  the  other  it  is  unchanged  in  size. 

The  pulmonary  type  may  be  confounded  with  pleurisy  or  with 
pneumonia,  but  the  physical  signs  and  many  symptoms  will 
clear  up  any  doubt.  In  doubtful  cases,  examination  of  the  blood 
and  treatment  with  quinine  will  furnish  irrefutable  evidence. 

The  algid  variety  resembles  cholera,  but  it  does  not  occur  in 
epidemics,  the  general  symptoms  of  cholera  are  wanting,  and 
treatment  decides  the  result. 

Jaundice  attends  the  hemorrhagic  form ;  hemorrhages  take 
place  from  various  mucous  surfaces  and  blood  is  found  in  the 
urine.  Hemorrhagic  malarial  fever  differs  from  paroxysmal 
hemoglobinuria  in  not  being  dependent  upon  exposure  to  cold, 
while  the  urine  contains  red  corpuscles  and  not  merely  hemo- 
globin.   Quinine  cures  the  one,  but  fails  to  influence  the  other. 

The  cerebral  type  is  to  be  distinguished  from  those  conditions 
that  give  rise  to  apoplexy  and  from  profound  intoxications  of 
various  kinds.  The  essential,  distinguishing  features  are  the 
occurrence  of  the  symptoms   in   the   course   of  an  attack  of 


MALTA    FEVER.  61 

malarial  fever,  the  absence  of  palsies  and  localizing  symptoms, 
the  tendency  to  recovery  under  treatment,  the  enlargement  of 
the  spleen,  the  presence  of  hematozoa  in  the  blood. 

How  are  typhoid  fever  and  malarial  fever  to  be  differentiated? 

Typical  cases  of  intermittent  and  remittent  fever  are  not 
likely  to  be  confounded  with  typhoid  fever,  but  if  an  intermit- 
tent or  remittent  has  existed  for  some  time,  uninfluenced  by 
medication,  a  typhoid  condition  develops,  and  the  symptoms 
may  occasion  some  doubt  in  diagnosis.  Under  such  circum- 
stances, the  previous  history  must  be  considered. 

The  diarrhea,  the  rose-spots,  the  temperature-course  of 
typhoid  fever  are  all  difterent  from  what  is  seen  in  malarial  fevers. 

The  reaction  of  the  urine  to  sulphanilic  acid  and  sodium  ni- 
trite, described  by  Ehrlich,  and  a  characteristic  bacillus  are  not 
found  in  malaria.  The  detection  of  the  plasraodia  of  malaria 
in  the  blood  or  the  reaction  of  typhoid  bacilli  to  the  blood  dis- 
sipates even  the  remotest  doubt. 

Malarial  fever  and  typhoid  fever  may  coexist  as  so-called 
typho-malarial  fever. 

How  does  syphilitic  fever  differ  from  malarial  fever  ? 

When  secondary  syphilis  is  marked  by  fever,  the  elevation  of 
temperature  usually  occurs  at  night  and  is  associated  with  bone- 
pains,  cutaneous  eruption  and  other  evidences  of  syphilis.  Cere- 
bral and  meningeal  syphilis  may  also  give  rise  to  febrile  move- 
ment. In  many  cases,  the  discovery  of  the  plasmodia  in  the 
blood  and  the  results  of  treatment  by  quinine  on  the  one  hand, 
and  the  results  of  treatment  by  mercury  and  iodides  on  the 
other  hand,  must  make  the  diagnosis. 


Malta  Fever. 

What  is  Malta  fever? 

Malta  fever,  also  known  as  Meditem-anean  fever,  rockfever,  Nea- 
politan fever,  undulant  fever,  is  an  acute  infections  disease  of 
warm  climates  dependent  upon  the  activity  of  a  specific  micro- 
coccus which  has  been  isolated  from  the  spleen. 


62  ESSENTIALS    OF   DIAGNOSIS. 

What  are  the  clinical  features  of  Malta  fever  ? 

The  disease  prevails  especially,  though  not  exclusively,  in 
countries  bordering  on  the  Mediterranean.  It  is  most  common 
in  summer,  and  it  may  be  epidemic.  The  period  of  incubation 
is  from  six  to  ten  days.  The  disorder  presents  an  irregular 
temperature-curve,  characterized  by  undulations  of  from  one  to 
three  weeks,  with  intermissions  of  two  or  more  days.  There 
are,  beside,  obstinate  constipation,  profuse  x^erspiration,  neu- 
ralgic pains,  arthritic  effusions,  anemia  and  debility  ;  there  may 
be  orchitis.  The  duration  is  uncertain,  if  not  indefinite,  without 
change  of  climate.  A  malignant  type,  of  short  duration,  and 
an  intermittent  type,  with  daily  pyrexia,  are  described.  The 
hlood  is  capable  of  arresting  the  motility  of  the  micrococcus 
melitensis. 

How  are  Malta  fever  and  malarial  fever  to  be  differentiated? 

Each  has  a  distinctive  temperature-curve ;  while  the  blood 
of  the  one  arrests  the  motility  of  the  micrococcus  melitensis 
and  that  of  the  other  contains  distinctive  plasmodia ;  quinine 
is  without  effect  upon  the  one  and  of  almost  specific  thera- 
peutic value  in  the  other. 

How  are  Malta  fever  and  typhoid  fever  to  be  differentiated  ? 

Malta  fever  is  unattended  with  the  epistaxis,  the .  diarrhea, 
the  rose-spots  of  typhoid  fever;  the  temperature  of  typhoid 
fever  is  of  continued  type,  that  of  Malta  fever  peculiarly  undu- 
lating ;  the  blood  of  the  one  arrests  the  motility  of  the  typhoid 
bacillus,  that  of  the  other  the  motility  of  the  micrococcus  meli- 
tensis ;  splenic  puncture  will  in  the  one  instance  disclose  the 
presence  of  the  bacillus,  in  the  other  that  of  the  micrococcus. 

Bubonic  Plague. 

What  are  the  clinical  features  of  the  bubonic  plague  ? 

The  plague  is  an  acute  contagious  disease  of  great  virulence, 
characterized  especially  by  lymphadenitis,  and  occurring  in 
epidemics,  especially  in  the  far  east.  It  is  dependent  upon  the 
activity  of  a  small,  motile  bacillus  that  gains  entrance  into  the 
blood  and  the  organs  of  the  body.  Insects  and  domestic  animals 
may  convey  the  infection.    The  disease  is  most  common  in  the 


BERIBERI.  6«3 

hot  season  and  is  predisposed  to  by  unfavorable  hygienic  con- 
ditions. The  period  of  incubation  is  three  or  four  days.  The 
attack  sets  in  with  headache,  pain  in  the  back,  stiffness  in  the 
extremities,  a  sense  of  anxiety  and  restlessness  and  depression 
of  spirits.  Respiration  is  accelerated  and  hemorrhage  may  take 
place,  especially  from  the  air-passages.  After  from  twelve  to 
thirty-six  hours  the  temperature  rises  and  tlie  puhe  becomes 
accelerated.  Symptoms  of  collapse  may  appear  and  death  en- 
sue. In  less  grave  cases  the  lymphatic  glands,  axillary,  cervical, 
popliteal,  become  enlarged,  and  they  may  undergo  suppuration 
or  gangrene.  Carbuncles,  as  well  as  petechiae,  may  ax)pear  on 
various  parts  of  the  body.     The  mortality  is  high. 

How  do  plague  and  typhus  fever  differ  ? 

Typhus  fever  is  wanting  in  the  hemorrhages,  the  buboes,  the 
carbuncles  of  plague,  and  its  duration  is  ordinarily  longer.  The 
discovery  of  the  specific  bacillus  in  the  blood  and  in  pus  from 
the  buboes  would  leave  no  doubt  as  to  the  existence  of  plague. 

How  are  plague  and  yellow  fever  to  be  differentiated  ? 

Yellow  fever  is  unattended  with  buboes  and  carbuncles,  while 
it  presents  jaundice,  black  vomit,  a  peculiar  facies  and  dis- 
proportion between  temperature  and  pulse-rate.  The  detection 
of  the  bacillus  pestis  in  the  blood  or  the  pus  from  the  buboes, 
or  the  arrest  of  the  motility  of  the  bacillus  icteroides  by  the 
blood,  wall  remove  any  doubt  in  diagnosis. 

Beriberi. 

What  is  beriberi? 

Berihen,  or  kakM,  is  a  disease  of  undetermined  origin,  occur- 
ring in  warm  climates  and  attended  with  symptoms  of  periph- 
eral neuritis,  together  with  anasarca. 

What  are  the  clinical  features  of  beriberi  ? 

The  disease  has  occurred  in  epidemics  and  has  been  attributed 
to  both  infection  and  food-intoxication.  It  is  predisposed  to  by 
unhygienic  conditions.  The  symptoms  include  paresthesia,  pain, 
anesthesia,  weakness  and  wasting  of  varying  degree  and  extent, 
Avith  reaction  of  degeneration  and  loss  of  reflexes.  There  occur, 
besides,  palpitation  of  the  heart,  shortness  of  breath,  albumin- 
uria, edema  and  effusion  into  serous  cavities. 


64  ESSENTIALS    OP   DIAGNOSIS. 


Yellow  Pever. 

What  are  the  characteristics  of  yellow  fever  ? 

Yellotv  fever  is  a  specific,  epidemic  disease  of  hot  climates, 
occurring  in  a  single  paroxysm  of  three  stages  :  the  firsts  a 
febrile  stage^  lasting  from  thirty-six  to  forty-eight  hours,  which 
sets  in  with  a  chill,  followed  by  fever,  with  capillary  congestion, 
especially  of  the  face  and  eyes,  pains  in  the  head,  the  back  and 
the  calves  of  the  legs,  restlessness  and  anxiety,  irritability  of  the 
stomach,  vomiting,  thirst,  constipation  ;  the  secmid,  a  stage  of 
remission  or  lull^  of  less  than  six  hours,  in  which  the  fever  sub- 
sides and  the  skin  assumes  a  deep-yellow  or  bronze  hue  ;  the 
third,  a  stage  of  renewal,  in  which  the  symptoms  reappear,  pros- 
tration becomes  pronounced  and  hemorrhages  take  place  from 
various  mucous  surfaces  ;  the  vomited  matters  present  a  charac- 
teristic black  appearance.  The  urine  usua;lly  contains  albumin 
and  often  casts.  Suppression  of  urine  may  occur.  The  flushed 
and  somewhat  swollen  face  and  the  injected  eyes  are  considered 
characteristic.  The  pidse  may  not  be  accelerated  even  though 
the  temperature  be  high. 

The  mind  is  usually  clear  almost  up  to  the  moment  of  death, 
but  in  some  cases  delirium  and  stupor  develop.  A  slender, 
motile  bacillus  has  been  found  in  the  blood  and  the  tissues,  and 
in  a  number  of  cases  the  blood  of  persons  suffering  from  yellow 
fever  has  caused  agglutination  and  arrested  the  motility  of  the 
specific  microorganisms  in  culture.  The  period  of  incubation  is 
three  or  four  days. 

Death  may  result  from  collapse  or  with  convulsions  and  the 
symptoms  of  uremia.  If  recovery  take  place,  convalescence  is 
often  gradual,  and  may  occasionally  be  interrupted  by  relapse. 
Some  cases  are  quite  mild,  recovery  taking  place  at  the  end  of 
the  first  stage.  Even  grave  cases  may  be  so  mild  in  the  first 
stage  as  to  be  unrecognized  ;  the  patient  walking  about,  to  be 
suddenly  seized  with  prostration,  quickly  followed  by  black 
vomit  and  death. 

An  attack  protects  against  subsequent  infection. 


YELLOW    FEVER.  65 

What  are  the  distinguishing  features  between  yellow  fever  and 
malarial  remittent  fever  with  jaundice  ? 

Yellow  fever  is  epidemic  ;  remittent  fever,  endemic.  Yellow 
fever  is  a  disease  of  a  single  paroxysm,  not  lasting  more  than  a 
week  ;  remittent  fever  is  a  disease  of  repeated  paroxysms,  of 
periodic  recurrence,  and  lasts  more  than  a  week. 

In  yellow  fever,  the  eyes  become  injected  and  watery,  the  ex- 
pression anxious  or  fierce.  In  remittent  fever,  there  is  no  espe- 
cial change  in  the  eyes  or  in  the  expression. 

Prostration  and  muscular  pains  are  decided  in  yellow  fever 
and  are  not  so  prominent  in  malarial  fever. 

Delirium  is  common  in  bilious  remittent  fever,  and  the  mind 
is  always  dull.  Delirium  is  not  common  in  yellow  fever,  and 
the  mind  is  usually  clear. 

The  pulse  may  become  very  slow  in  yellow  fever  ;  it  is  always 
quick  in  remittent  fever. 

Hemorrhages  from  mucous  surfaces  take  place  in  yellow 
fever  ;  not  in  ordinary  remittent  fever. 

The  urine  of  yellow  fever  contains  albumin,  and  suppression 
may  take  place  ;  the  urine  of  remittent  fever  contains  no  albu- 
min and  suppression  does  not  commonly  occur.  Bile-pigment 
gradually  disappears  from  the  urine  of  yellow  fever  and  increases 
in  the  urine  of  bilious  remittent  fever. 

An  attack  of  yellow  fever  confers  immunity  from  subsequent 
infection ;  one  attack  of  remittent  fever  predisposes  to  other 
attacks.  Yellow  fever  is  commouly  fatal,  remittent  fever  rarely 
fiital. 

The  treatment  of  yellow  fever  is  uncertain ;  remittent  fever 
yields  to  quinine. 

Plasmodia  malarise  are  not  found  in  the  blood  in  uncompli- 
cated yellow  fever;  they  are  diagnostic  of  malarial  fever.  The 
blood  in  yellow  fever  causes,  further,  agglutination  and  arrests 
the  motility  of  cultures  of  the  bacillus  icteroides. 

How  are  hemorrhagic  malarial  fever  and  yellow  fever  to  be 
differentiated  ? 

Both  hemorrhagic  malarial  fever  and  yellow  fever  occur  in  hot 
climates  and  are  attended  with  jaundice,  hematemesis  and  other 
hemorrhages. 


6Q  ESSENTIALS    OP    DIAGNOSIS. 

Yellow  fever,  however,  is  epidemic  ;  hemorrhagic  malarial 
fever,  endemic.  The  former  consists  of  but  a  single  parox3^sm, 
of  three  stages,  including  a  remission  ;  the  latter  is  marked  by  a 
series  of  paroxysms,  each  followed  by  a  remission. 

Black  vomit  is  the  more  characteristic  of  yellow  fever  ;  hem- 
orrhage from  the  kidneys,  of  hemorrhagic  malarial  fever.  Al- 
bumin and  casts  are  commonly  found  in  the  urine  in  yellow 
fever  ;  not  in  malarial  fever.  An  attack  of  yellow  fever  con- 
fers immunity  from  subsequent  infection  ;  an  attack  of  malarial 
fever  predisposes  to  the  occurrence  of  other  attacks.  The  de- 
tection of  the  Plasmodia  of  malaria  in  the  blood  or  of  the 
specific  reaction  in  yellow  fever  establishes  the  diagnosis. 

How  is  yellow  fever  to  be  distinguished  from  acute  yellow 
atrophy  of  the  liver  ? 

Yellow  fever  is  epidemic  ;  acute  yellow  atrophy  is  sporadic. 
In  acute  yellow  atrophy,  the  area  of  hepatic  dulness  becomes 
rapidly  and  decidedly  diminished  ;  in  yellow  fever,  there  is  either 
enlargement  or  no  demonstrable  change. 

Yellow  fever  is,  and  acute  yellow  atrophy  is  not,  attended  with 
a  distinct  remission  in  the  severity  of  the  attack.  Yellow  fever  is 
sometimes  followed  by  recovery ;  acute  yellow  atrophy  but  rarely. 

The  injection  of  the  eyes,  the  pains  in  the  back  and  extremi- 
ties, found  in  yellow  fever,  are  wanting  in  acute  yellow  atrophy 
of  the  liver. 

In  acute  yellow  atrophy,  leucin  and  tyrosin  are  found  in  the 
urine,  and  while  cerebral  symptoms  are  more  pronounced  than 
in  yellow  fever,  the  temperature  never  rises  so  high  and  may 
even  be  subnormal. 

What  are  the  clinical  differences  between  yellow  fever  and 
dengue  ? 

When  yellow  fever  and  dengue  prevail  synchronously,  the 
differentiation  may  be  exceedingly  difficult.  Dengue  is,  how- 
ever, likely  to  be  unattended  with  the  peculiar  fades  of  yellow 
fever,  the  albuminuria,  the  relative  slowness  of  pulse,  the  hemor- 
rhages and  the  jaundice  ;  while  the  agglutinating  and  sediment- 
ing  influence  of  the  blood  on  the  bacillus  icteroides  removes 
any  doubt. 


Weil's  DISEASE.  67 


Weil's  Disease. 

What  are  the  symptoms  of  Weil's  disease  ? 

WeiVs  disease,  also  called  acute  infective  jaundice,  is  an  inter- 
mittent febrile  afiection,  usually  exhibiting  two  periods  of 
activity  separated  by  an  uncertain  interval ;  the  first  of  a  little 
more,  the  second  of  a  little  less,  than  a  week's  duration.  The 
disease  may  set  in  abruptly  with  nausea  and  vomiting.  The 
temperature  at  once  rises  to  a  considerable  height,  but  falls 
decidedly  on  about  the  night  of  the  fifth  day  ;  subsequently 
declining  gradually  until  the  normal  level  is  reached.  After  an 
afebrile  period  of  from  twenty-four  hours  to  a  week,  there  is  a 
return  of  fever  lasting  a  few  days  or  a  week. 

The  attack  is  characterized  by  headache,  vertigo,  malaise,  de- 
bilit}^,  somnolence,  and,  sometimes,  nocturnal  fever  and  restless- 
ness, hyperesthesia,  diarrhea,  muscular  pains  and  jaundice. 
The  pulse  is  small  and  frequent  and  sometimes  dicrotic.  The 
resfjiration  is  accelerated.  The  areas  of  splenic  and  hepatic  per- 
cussion-dulness  are  increased.  The  urine  passed  is  diminished 
in  quantity  and  contains  bile-pigment,  bile-acids,  albumin  and 
casts.  Hemorrhages  from  various  mucous  surfaces  maj^  take 
place — epistaxis,  hematemesis,  hemoptysis  and  intestinal  hem- 
orrhage.    Petechial  spots  may  appear  in  the  skin. 

The  disease  has  been  observed  most  commonly  in  summer 
and  in  vigorous  young  men,  butchers  and  soldiers  seeming  to 
display  a  peculiar  proclivity.  Similar  manifestations  have  fol- 
lowed poisoned  wounds.  In  fatal  cases,  degeneration  of  the 
liver  and  kidneys  and  spleen  has  been  found.  Parotiditis, 
pneumonia,  iridocyclitis  and  motor  weakness  have  been  sequelae. 
In  cases  that  recover,  the  convalescence  is  protracted. 

How  are  Weil's  disease  and  yellow  fever  to  be  differentiated  ? 

A7eil's  disease  and  yellow  fever  probably  exhibit  a  closer  re- 
semblance in  description  than  in  actualit}'. 

Weil's  disease  shows  a  special  predisposition  for  young  adults, 
especially  butchers  and  soldiers  ;  yellow  fever  occurs  in  epidem- 
ics and  does  not   confine   itself  to  any  class  of  individuals. 


68  ESSENTIALS    OF    DIAGNOSIS. 

Diarrhea  is  the  rule  in  Weil's  disease  ;  constipation  in  yellow 
fever.  The  initial  stage  of  yellow  fever  is  of  shorter  duration  ; 
it  is  earlier  attended  with  a  remission  ;  the  remission  is  less 
complete,  and  both  the  remission  and  final  stage  are  shorter 
than  is  the  case  in  Weil's  disease.  Black  vomit  is  not  common 
in  Weil's  disease  ;  the  injection  and  excitement  are  less  than  in 
yellow  fever.  Weil's  disease  does  not  present  the  peculiar 
facies  of  yellow  fever,  nor  the  relative  slowing  of  pulse. 

Leprosy. 

What  is  leprosy  ? 

Leprosy  is  a  chronic  infectious  disease  dependent  upon  the 
activity  of  a  specific  bacillus  resembling  that  of  tubercle. 

"What  are  the  symptoms  of  leprosy  ? 

The  disease  occurs  in  two  forms,  the  tubercular  and  the  anes- 
thetic. In  the  former,  areas  of  cutaneous  erythema  appear, 
which  subsequently  become  pigmented  and  finally  the  seat  of 
nodules.  The  hair  falls  out  and  the  mucous  membranes  may 
be  involved.  Anesthetic  leprosy  is  attended  with  pains  and 
hyperesthesia,  followed  by  anesthesia  and  trophic  changes.  The 
nerves  are  at  first  tender,  but  subsequently  thickened  and 
nodular.  Blisters  may  form  and  rupture,  leaving  ulcers.  The 
digits  may  undergo  contractures  and  necrosis. 

The  Exanthemata. 

What  are  the  exanthemata  ? 

The  term  exanthemata  or  eruptive  fecers  is  applied  to  a  group 
of  contagious,  epidemic  diseases,  each  depending  upon  a  specific 
infection  and  having  as  prominent  signs,  fever  and  specifically 
characteristic  eruptions  on  the  skin  and  often  on  the  visible 
mucous  membranes.  As  exanthemata  are  commonly  described 
scarlatina  or  scarlet  fever;  morbilli  or  measles;  rubella,  also 
called  German  measles,  French  measles  or  Rotheln  ;  variola  or 
smallpox  and  its  modification,  varioloid;  vaccinia — the  usual 
consequence  of  vaccination ;  varicella  or  chicken-pox.  Diph- 
theria and  erysipelas  might  also  be  included. 


MORBILLI  —  MEASLES, 


69 


Morbilli— Measles. 

Upon  what  does  the  diagnosis  of  morbilli  depend  ? 

MorhiUi  or  measles,  also  called  rubeola,  is  an  acute,  contagious 
disease,  common  in  children,  attended  with  catarrhal  symptoms 
(coryza,  rhinitis,  pharyngitis,  laryngitis,  bronchitis,  conjuncti- 
vitis), febrile  elevation  of  temperature  and  a  characteristic  ex- 
authem. 

The  period  of  incuhation  is  from  seven  to  fourteen  days.  The 
onset  is  somewhat  abrupt,  with  a  quick  rise  of  temperature  to  from 
102^  to  104°  F.,  more  or  less  headache,  restlessness,  injection 
and  watering  of  the  eyes,  sneezing,  running  from  the  nose,  often 
swelling  of  the  nose  and  lip,  perhaps  cough  and  slight  sore- 
throat.  Digestion  is  commonly  disturbed,  and  the  urine  may  be 
scanty.     The  temperature  (Fig.  11)  undergoes  a  considerable  ele- 

FlG.  11. 


400° 


BOO" 


38-0° 


37-0'^ 


300° 


B^  ^^  SBi  iSSS  SB9  HBH I 


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Temperature-chart  of  measles.     (Striimpell.) 

vation  with  the  onset  of  the  attack,  declining  on  the  second  or 
third  day,  to  rise  again  on  the  fourth,  with  the  appearance  of  the 
eruption.     This  consists  of  coarse,  pink  papules,  primarily  dis- 


70  ESSENTIALS    OF    DIAGNOSIS. 

Crete,  then  becoming  surrounded  by  a  somewhat  paler  border  and 
soon  coalescing,  to  form  slightly  elevated  patches  arranged  in 
crescentic  form,  with  intervening  healthy  skin.  The  eruption 
first  appears  upon  the  face  and  neck,  then  upon  the  body.  The 
fever  declines  and  the  eruption  begins  to  disappear  between  the 
fifth  and  the  seventh  day.  Branny  desquamation  follows  as  the 
attack  comes  to  an  end  on  the  ninth  day.  The  eruption  may 
usually  be  detected  in  the  throat  a  day  or  two  in  advance  of  its 
appearance  on  the  skin.  Small,  round,  bluish-white  spots,  sur- 
rounded by  an  area  of  congestion  or  upon  a  diffuse  red  back- 
ground, may  be  seen  on  the  buccal  mucous  membrane,  espe- 
ciall)'^  opposite  the  lower  molar  teeth.  Sometimes  a  sense  of 
rubbing  or  crackling  may  be  elicited  on  pressure  upon  the 
abdomen,  from  the  presence  of  the  eruption  on  the  peritoneum. 
An  attack  of  measles  commonly  protects  against  subsequent 
infection  ;  though  second  attacks  are  not  rare  and  third  attacks 
not  remarkable.  The  disease  is  ordinarily  mild  and  benign  ; 
sometimes,  however,  it  is  malignant  and  hemorrhagic  (black 
measles).  Lobular  pneumonia  and  catarrhal  otitis  media  are  not 
uncommon  complications.  An  attack  of  measles  is  likely  to  pre- 
cipitate the  development  of  tuberculosis  in  one  predisposed  and 
to  accelerate  the  course  of  the  disease  when  it  already  exists. 

How  does  morbilli  differ  from  typhus  fever  ? 

Typhus  fever  is  of  longer  duration  and  decidedly  more  grave 
than  measles,  than  w'hich  it  is  relatively  less  common  in  chil- 
dren. While  the  eruption  of  measles  in  some  degree  resembles 
that  of  typhus,  it  appears  earlier  and,  as  a  rule,  has  no  tendency 
to  become  petechial ;  it  begins  on  the  face,  while  in  typhus  the 
face  escapes.  The  catarrhal  symptoms  of  measles  are  wanting 
in  typhus  ;  the  profound  nervous  depression  of  typhus  is  not 
seen  in  measles.  Typhus  in  North  America  is  rare  and  as  a  rule 
imported,  most  frequently  by  emigrant-ships. 

Scarlatina — Scarlet  Fever. 

What  are  the  symptoms  of  scarlatina  ? 

Scarlatina  is  an  acute,  contagious  disease,  to  which  children 


SCARLATINA — SCARLET    FEVER.  71 

and  young  persons  evince  a  special  predisposition.    An  attack 
confers  relative  immunity  from  subsequent  infection. 

The  period  of  incubation  may  be  short.  It  varies  from  twenty- 
four  hours  to  a  week,  rarely  ten  days.  The  onset  is  usually 
abrupt,  perhaps  attended  with  vomiting  or  convulsions.  The 
temperature  at  once  rises  to  a  considerable  height  (104°  or  105° 
F.)  and  the  piJse  attains  a  striking  frequency.  In  the  first 
twenty-four  hours,  or  sometimes  a  little  later,  a  diffuse,  fine, 
punctiform,  reel  rash  appears,  at  first  on  the  neck  and  breast  and 
in  the  flexures  of  the  joints,  soon  spreading  as  a  uniform  scarlet 
flush  over  the  greater  part  of  the  body.  Pressure  causes  tempo- 
rary dissipation  of  the  redness.  There  are  intense  subjective 
burning  and  itching  of  the  skin. 

The  throat  is  usually  sore  and  swallowing  is  painful.  The 
fauces  and  palate  are  reddened,  the  tonsils  and  uvula  and  the 
adjacent  cervical  glands  are  enlarged  and  there  is  stiffiiess  of 
the  muscles  of  the  neck.  The  scarlet  discoloration  ma}^  some- 
times be  detected  in  the  throat,  especially  on  the  free  border 
of  the  soft  palate  and  on  the  uvula,  in  advance  of  its  appearance 
on  the  skin.  The  throat-aflection  is  often  ulcerative  or  pseudo- 
membranous in  character.  The  larynx  is  rarely  invaded.  The 
nose  is  usually  involved  and  there  is  more  or  less  serous  or  sero- 
purulent  discharge.  The  inflammation  may  extend  into  the  Eus- 
tachian tube  and  involve  the  auditory  apparatus.  Suppurative 
otitis  is  not  an  uncommon  complication,  and  perforation  and 
deafness  may  result. 

The  tongue  is  at  first  heavily  coated,  but,  in  the  course  of  a 
little  while,  the  dense  fur  is  cast  off",  exposing  the  surface  of  the 
reddened  organ,  with  its  enlarged  and  prominent  papillae— an 
appearance  characteristically  described  by  the  designation 
"  strawberry  tongue."  Thirst  is  often  great.  Digestion  is  de- 
ranged. The  urine  is  scanty.  The  number  of  colorless  blood- 
corpuscles  is  increased. 

Severe  nei'vous  symptoms  may  occur,  twitchings  or  convulsions, 
restlessness,  insomnia,  delirium,  stupor,  fatal  coma ;  or  the  ner- 
vous disturbances  may  be  very  mild  and  cease  with  the  setting 
in  of  convalescence. 

In  favorable  cases,  the  eruption  fades  by  the  fourth  or  fifth  da}-. 


72 


ESSENTIALS    OF    DIAGNOSIS. 


The  temperature,  which  has  remained  high,  begins  to  decline  ; 
defervescence  taking  phice  by  somevvliat  rapid  lysis  (Fig.  12). 
At  the  end  of  a  week  or  nine  days,  the  skin  undergoes  a  fur- 
furaceous  or  membranaceous  desquamation,  tlie  temperature 
falls  to  the  normal  and  convalescence  may  set  in.  Persistence 
of  high  temperature  into  the  second  week  is  not  common  and 
usually  denotes  a  complication.  So,  too,  a  sudden  recrudescence 
of  pyrexia,  after  decline  has  begun,  indicates  suppuration  or 
other  accident.  Convalescence  may  be  interrupted  by  the  ap- 
pearance  of  symptoms   of  an   acute  nephritis;    edema  of  the 


Fig.  12. 
1.        23         4  567  89 


410'' 


40-0° 


ag-Qo 


38-0° 


■■WilSiMMHIIHaBBBBBHl 


■(■■■■■■■■■■■kVFllHHH 
■^■■■■■■■■■■IWBHH 

■■■■BHHHHBHHHHIVHB 
i  BBBilBBBHBBBBIkIBB 


37  0°    Ifl 


w_ 


Temperature-chart  of  scarlatina.     (Striimpell.) 

face  and  body,  with  diminished  elimination  of  a  dense,  high- 
colored  or  smoky-looking  urine,  containing  considerable  albumin 
and  blood,  as  well  as  blood-casts  and  epithelial  casts  of  the  uri- 
niferous  tubules.  Not  rarely,  albuminuria  and  other  evidences 
of  renal  congestion  or  inflammation  may  be  detected  prior  to  the 
appearance  of  edema.  With  or  without  suppression  of  urine, 
there  may  occur  convulsions,  delirium,  stupor,  coma  and  death. 
Another  rather  frequent  complication  is  arthritis,  which  may 
involve  a  single  joint  or  several  joints.  Sometimes,  with  or  with- 
out joint-symptoms,  there  is  endocarditis,  pericarditis  or  pleu- 
ritis.    Permanent  valvular  lesions  of  the  heart  may  be  sequelae. 


SCARLATINA SCARLET  FEVER.         73 

Various  lypeH  of  scarlatina  are  observed  in  addition  to  the 
ordinary  form.  When  throat-symptoms  predominate,  the  attack 
is  called  "anginose."  Sometimes  the  disease  is  mild  or  abortive. 
At  other  times  it  is  malignant  in  virulence.  In  malignant  cases, 
the  rash  may  be  delayed  ;  it  may  be  pale  and  indistinct  or  dark 
and  livid.  Cases  in  which  the  rash  is  wanting  may  be  mild  or 
severe.  This  form  is  called  "larval"  or  "scarlatina  sine  ex- 
anthemate."  In  these  cases,  dropsy  or  suppression  of  urine 
may  be  the  first  symptom  to  attract  attention.  Anasarca  may 
occur  without  nephritis,  but  its  dissociated  occurrence  is  not 
common.     Scarlatina  is  said  occasionally  to  be  hemorrhagic. 

How  are  scarlatina  and  measles  to  be  differentiated  ? 

Scarlatina  usually  sets  in  with  vomiting  or  convulsions ; 
measles  rarely  so  begins.  Rather  severe  sore-throat  and  gland- 
ular enlargement  characterize  scarlatina  ;  catarrhal  sj^mptoms 
are  present  in  measles.  The  great  rapidity  of  pulse  and  eleva- 
tion of  temperature  commonly  observed  in  scarlatina  are  want- 
ing in  measles  The  eruption  of  scarlatina  appears  on  the  first 
or  second  day  of  the  disease  and  is  finely  punctate,  occasioning 
an  appearance  of  diflfuse  redness ;  the  eruption  of  measles  ap- 
pears not  before  the  third  day  and  is  commonly  papular,  arranged 
crescentically,  with  areas  of  intervening  healthy  skin.  After  a 
preliminary  elevation,  the  temperature  of  measles  falls  on  the 
second  or  third  day,  to  rise  again  with  the  appearance  of  the 
eruption,  then  to  subside  rapidly  ;  the  temperature  of  scarlatina 
at  once  mounts  high  and,  after  a  few  days,  declines  gradually. 
JS'ervous  symptoms  are  decided  in  scarlatina,  wanting  in  measles. 

What  are  the  features  that  differentiate  acute  exfoliative 
dermatitis  and  scarlet  fever? 

Acute  exfoliative  dermatitis  may  set  in  suddenly  with  febrile 
symptoms,  and  the  exanthem  persist  for  five  or  six  days  and 
be  followed  by  desquamation.  It  is,  however,  unattended  with 
the  peculiar  appearance  of  the  tongue,  the  angina,  the  grave 
constitutional  symptoms  and  complications  and  the  leuko- 
cytosis of  scarlet  fever. 

How  is  scarlet  fever  to  be  differentiated  from  toxic  dermatitis? 

Inflammation  of  the  skin  of  varying   intensity  and  extent 


74  ESSENTIALS   OP    DIAGNOSIS. 

may  arise  from  many  toxic  influences.  The  exanthem  of  scar- 
let fever  may  itself  be  considered  to  be  of  this  nature,  and  nu- 
merous other  infectious  diseases  and  processes,  as,  for  instance, 
rubella,  variola,  diphtheria,  septicemia,  typhoid  fever,  are  capa- 
ble of  giving  rise  to  a  similar  manifestation.  Cutaneous  ery- 
thema has  been  observed  also  after  the  use  of  medicaments,  as, 
for  instance,  quinine,  belladonna,  atropin,  bromids,  and  of  anti- 
toxin; and  as  a  result  of  direct  irritation  of  the  skin,  as,  for 
instance,  by  rhus  toxicodendron  and  turpentine.  The  diagnosis 
will  be  based  upon  the  history,  upon  a  recognition  of  the  etio- 
logic  factors  and  upon  the  course  of  the  respective  affections. 
High  fever,  rapid  pulse,  profound  constitutional  disturbance, 
sore  throat,  albuminuria,  anasarca,  desquamation,  when  pres- 
ent, make  up  a  clinical  picture  that  is  not  readily  mistaken. 


Rubella. 

What  are  the  symptoms  of  rubella  ? 

Rubella,  also  called  Rotheln,  roseola,  German  measles  and 
French  measles,  is  an  acute,  contagious  exanthem,  presenting 
an  eruption  resembling  that  of  morbilli  and  throat-symp- 
toms like  those  of  scarlatina.  An  attack  protects  from  sub- 
sequent attacks,  but  not  from  measles  or  scarlet  fever;  neither 
does  an  attack  of  scarlet  fever  or  one  of  measles  confer  im- 
munity from  rubella.  The  period  of  incubation  of  rubella  is 
from  five  to  twenty-one  days.  The  onset  is  usually  abrupt. 
The  temperature  is  moderate;  the  pulse  is  not  very  rapid.  In 
the  course  of  a  day  or  two  there  appears,  first  upon  the 
face  and  then  progressively  invading  the  trunk  and  the  ex- 
tremities, an  eruption  of  small  pinkish  papules,  usually  sepa- 
rated from  one  another  by  skin  of  normal  appearance.  Some- 
times the  intervening  skin  is  erythematous.  The  eruption  lasts 
for  from  four  days  to  a  week,  is  attended  with  itching  and  is 
sometimes  followed  by  slight  desquamation.  The  throat  is 
usually  sore,  the  fauces  reddened  and  the  cervical  glands  en- 
larged. Catarrhal  symptoms  are  common.  The  course  of  the 
disease  is  usually  mild  and  uncomplicated. 


VARIOLA  —  SMALLPOX.  75 

How  are  rubella  and  scarlatina  to  be  differentiated  ? 

Rubella  is  inherently  a  mild  disease  ;  scarlatina  is  never  with- 
out gravity.  Rubella  lacks  the  rapid  pulse,  the  high  tempera- 
ture, the  *'  strawberry  tongue  ''  and  the  grave  complications  of 
scarlatina.  The  eruption  of  rubella  more  nearly  resembles 
that  of  morbilli  than  that  of  scarlati)''a.  Slight  edema  of  the 
hands,  sometimes  present  in  scarlatina,  is  not  found  in  ru- 
bella. Neither  rubella  nor  scarlatina  is  protective  against  the 
other. 

How  are  rubella  and  morbilli  to  be  differentiated  ? 

Rubella  resembles  morbilli  in  its  rash,  in  its  mildness  and  in 
the  catarrhal  symptoms  it  presents.  The  eruption  of  Rotheln, 
however,  is  brighter-hued  and  does  not  show  a  tendency  to 
crescentic  arrangement,  w^hile  it  appears  earlier  and  the  indi- 
vidual papules  are  smaller  than  is  the  case  in  morbilli.  Rubella 
is  milder  than  morbilli,  even  as  relates  to  the  catarrhal  symp- 
toms.    An  attack  of  either  confers  no  immunity  from  the  other. 

Variola— Smallpox. 

Upon  what  does  the  diagnosis  of  smallpox  depend  ? 

Small2:)0x  or  variola  is  an  acute,  contagious,  epidemic  disease, 
setting  in  with  a  chill,  pains  in  the  back,  head  and  extremities, 
nausea  and  vomiting,  elevation  of  temperature  to  102°  or  103"  F., 

Fig.  13. 


2          3          4          5          C          7          8          9        10        n         12        13        !4         15         IG        17        18 

c. 

■f^  ■IIB  HH  HBl  ■■  HB  BH  ^H  ■■■■  HB  ■■  ■■  Hi  ■■■■■■  ■■ 

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40  ■0» 

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HHk'WBHBBBBMiimf^HMIlHHBiBiHHBHHH      H  ■■■■■■ 

HHI IIH  HH  HH  HH  HHBIIM^^B  HH  HH  HH  HH  HB     H  BH  BB  BB 

HBHBBBBBBBBBBBIHBiW^lBBBBBHHB     BBBBBBB 

■■■IMBBHBBHBBnBHBraAlBBBTilBBBB     BBBBBBB 

39"0° 

■BBIMBBBBBBBBViBBBBBBfiWrAIBBBB     BBBBBBB 

0HIH1U13H^BBI^B^l^lHIVllVMlHI^HBH^I  V^BIH'A^^BHiUVil      IH^HHUHilH^I 

BBBBlWRBnSnBBBHBBBBBBBkWflBB     MBBBBBB 

38-0« 

■■BBBBBBBBBBBBBBBBBBBBITJaiTlBlVMBBBBBB 

BgBBia»BIBBBSBBSSBSBSiSEJ89rSsSH 

■■BBBBBBBBBBBBBBBBBBBBBBBBBBBBMBINB 

ST'0» 

■BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 

■BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 

Temperature-chart  of  smallpox.     (Striimpell.) 

with  marked  exacerbations,  increased  rapidity  of  pulse,  and  a 


76  ESSENTIALS    OF    DIAGNOSIS. 

diffuse,  red,  scarlatiniform  rash  or  a  macular  measly  rash  that  is 
followed  on  the  third  or  fourth  day  by  the  appearance  of  pap- 
ules; when  the  temperature  declines.  The  papules  commonly 
appear  first  on  the  lips  and  forehead.  The  preceding  red  or  ma- 
cular rash  usually  appears  first  on  the  abdomen,  the  arms,  and 
in  the  neighborhood  of  the  groin.  The  fauces  are  usually  red- 
dened. There  may  be  decided  catarrhal  symptoms.  In  the 
course  of  the  succeeding  four  or  five  days,  the  papules  b'ecome 
vesicles  and  the  vesicles,  in  turn,  pustules.  The  surface  of  the 
pustule  is  depressed  at  the  middle — umblHcated.  Each  pustule 
is  surrounded  by  an  area  of  redness,  constituting  an  areola. 
On  the  eighth  or  ninth  day  the  pustules  rupture  and  discharge 
their  contents,  and  the  temperature  again  ibises  (secondary  or 
pyemic  fever).  (Fig.  13.)  Secondary  fever  is  sometimes  an- 
nounced by  rigor,  and  its  temperature-course  is  remittent.  The 
evening  temperature  reaches  from  103°  to  105°  F.  The  period 
of  maturation  and  discharge  lasts  from  three  to  five  days,  when 
crusts  form  and  the  temperature  declines  ;  in  the  course  of  a 
week  the  scabs  fall  off,  leaving  red  cicatrices,  which  in  the 
course  of  time  become  whiter  and  contracted,  leaving  "pits." 
The  spleen  is  enlarged,  and  active  leukocytosis  is  present. 

Ulceration  of  the  larynx  and  trachea,  bronchitis,  pneumonia, 
pleurisy  or  orchitis  may  cotnplicate  variola.  Secondary  inflam- 
mations are  most  likely  to  occur  coincidently  with  the  second- 
ary fever.  The  eye  frequently  suffers  permanent  injury  as  the 
result  of  an  attack  of  smallpox.  The  period  of  incubation  of 
variola  is  about  twelve  days. 

What  are  the  varieties  of  smallpox  ? 

Smallpox  may  be  simple  or  discrete,  confluent  or  hemorrhagic; 
it  may  assume  a  malignant  character. 

What  are  the  characteristics  of  discrete  smallpox? 

Discrete  smallpox  is  the  mildest  type  of  smallpox  ;  the  erup- 
tion is  least  profuse,  the  pustules  occurring  isolated.  Sometimes 
the  pustules  are  in  contact  at  their  periphery,  when  the  disease 
is  said  to  be  coherent. 

What  are  the  characteristics  of  confluent  smallpox  ? 
In  confluent  smallpjox,  the  pustules  are  numerous  and  run  into 


VARIOLA  —  SMALLPOX.  77 

one  another.  The  temperature  fails  to  decline  with  the  appear- 
ance of  the  eruption  and  is  apt  to  be  decidedly  high  during  the 
period  of  maturation.  The  gravity  of  the  case  is  greater  than 
in  discrete  smallpox.  TyJDhoid  symptoms,  delirium,  stupor  and 
fatal  coma  may  develop ;  or  death  may  be  brought  about  by 
diarrhea,  ulceration  of  the  larynx  or  trachea,  endocarditis  or 
other  complication. 

What  are  the  characteristics  of  hemorrhagic  variola  ? 

In  hemorrhagic  variola  the  exanthem  may  be  from  the  first 
constituted  of  ecchymoses,  while  hemorrhages  may  take  place 
from  any  of  the  mucous  membranes.  This  is  the  gravest  form. 
Few  cases  recover.  Sometimes  hemorrhage  does  not  take 
place  until  the  vesicular  or  pustular  stage  is  reached. 

What  is  malignant  smallpox  ? 

The  epithet  malvjnant  is  sometimes  applied  to  a  variety  of 
smallpox,  most  frequently  encountered  at  the  beginning  of  an 
epidemic,  in  which  death  may  occur  early  in  stupor,  following 
delirium,  the  eruption  being  ill-defined  and  perhaps  only  devel- 
oped post-mortem. 

What  is  varioloid  ? 

Varioloid  is  smallpox  modified  by  vaccination  or  by  a  previ- 
ous attack  of  smallpox.  The  symptoms  of  the  disease  are  similar 
to  those  of  smallpox,  but  milder  in  degree  and  shorter  in  dura- 
tion ;  secondary  fever  is  absent.  The  eruption  of  varioloid  com- 
monly appears  on  the  second  or  third  day  ;  that  of  variola  on  the 
fourth  day.  The  course  of  varioloid  is  completed  in  about  four- 
teen days  ;  that  of  variola  in  about  twenty-one  days. 

What  is  vaccination  ? 

Vaccination  consists  in  the  introduction  of  the  virus  of  cow- 
pock'  into  the  lymphatic  system  of  man,  usually  through  the  skin 

^  What  is  meant  by  humanized  virus  ? 

Humanized  virus  is  vacciue-lymph  that  is  not  taken  directly  from  the 
cow  (or  calf),  but  from  the  vaccine- pustule  of  a  human  being,  usually  a 
child,  who  may  have  been  inoculated  with  matter  obtained  from  another 
child,  or  from  the  cow.  Unless  one  is  sure  as  to  the  purity  of  the  ante- 
cedents of  the  source  of  the  humanized  virus,  bovine  virus  is  to.  be  pre- 
ferred. 


78  ESSENTIALS    OF    DIAGNOSIS. 

denuded  of  its  epithelium,  as  a  protection  against  variola.  The 
protective  influence  continues  for  a  period  of  about  seven  years, 
at  the  end  of  which  time  vaccination  should  be  repeated. 

What  is  vaccinia  ? 

Vaccinia  is  the  result  of  the  inoculation  of  cowpock  iu  human 
beings,  and  is  protective  against  smallpox.  For  two  or  three 
days  following  vaccination,  little  is  to  be  observed,  locally  or 
constitutionally.  At  the  end  of  this  time,  the  site  of  inoculation 
presents  an  appearance  of  slight  redness,  which  in  the  next  few 
days  becomes  intensified,  as  a  vesicle  forms  and  becomes  trans- 
formed into  a  pustule,  umbilicated  and  surrounded  by  a  distinct 
areola.  This  process  goes  on  for  four  or  five  days,  when  the  pus- 
tule ruptures  and  the  intensity  of  the  inflammation  gradually 
subsides.  In  the  course  of  a  week  or  ten  days,  the  crust  falls 
off  and  leaves  a  reddish  cicatrix,  which  subsequently  becomes 
white  and  depressed. 

How  does  smallpox  differ  from  measles  ? 

The  eruption  of  measles  is  coarsely  papular  throughout,  with 
a  tendency  to  crescentic  arrangement,  and  is  followed  by  branny 
desquamation ;  that  of  smallpox  is  irregular  in  arrangement 
and  passes  from  the  papular  into  a  vesicular  and  then  into  a 
pustular  stage,  sometimes  leaving  disflguring  cicatrices.  In 
measles,  after  a  previous  decline  in  temperature,  the  appearance  of 
the  eruption  is  attended  with  renewed  elevation ;  in  smallpox,  the  tem- 
perature declines  with  the  appearance  of  the  rash  and  reascends  with 
the  occurrence  of  pustulation.  Smallpox  is  a  grave  disease, 
lasting  three  weeks  ;  measles  is  a  mild  disease,  lasting  less  than 
two  weeks. 

How  are  variola  and  scarlatina  to  be  differentiated  ? 

Smallpox  may  be  attended  with  a  primary,  difluse  red  rash, 
not  unlike  that  of  scarlatina,  but,  at  the  end  of  three  or  four 
days,  papules  appear,  in  turn  to  be  succeeded  by  vesicles  and 
pustules,  flnally  leaving  disfiguring  cicatrices.  With  the  ap- 
pearance of  the  secondary  rash,  the  temperature  declines.  The 
eruption  of  scarlatina  undergoes  no  change  and  terminates  in 
desquamation.  The  temperature  is  high  from  the  outset  and  is 
continuous.     Variola  is  not  characterized  by  the  same  rapidity 


VARICELLA CHICKENPOX.  79 

of  pulse  or  by  the  typical  "strawberry  tongue"  of  scarlatina. 
Uncomplicated  scarlatina  is  a  disease  of  less  than  two  weeks' 
duration  ;  variola  rarely  lasts  less  tliau  three. 

Varicella — Chickenpox. 

What  are  the  characteristics  of  varicella  ? 

Varicella  or  chickenpox  is  a  mild,  contagious  disease  of  child- 
hood, attended  with  moderate  elevation  of  temperature  and  the 
appearance  on  the  first  or  second  day  of  an  eruption  of  papules, 
which  in  turn  become  transformed  into  vesicles.  These  may 
occasionally  form  bullae,  or  undergo  suppuration  or  gangrene. 
The  eruption  appears  on  the  trunk  and  extremities,  on  the  scalp 
and  face.  It  comes  out  in  crops  and  continues  for  three  or 
four  days,  the  vesicles  desiccating  and  falling  off,  occasionally 
leaving  cicatrices.  The  period  of  incubation  is  from  two  to  three 
weeks. 

How  does  varicella  differ  from  smallpox  ? 

Varicella  is  a  mild  disease  ;  variola  a  grave  disease.  The  erup- 
tion of  smallpox  appears  on  the  third  or  fourth  day  and  passes 
through  papular  and  vesicular  stages  to  become  pustular  ;  that 
of  varicella  appears  on  the  first  or  second  day  and  does  not  pass 
beyond  a  vesicular  stage.  The  cutaneous  lesion  of  variola  has, 
further,  a  peculiar,  shot-like  hardness ;  it  is  surrounded  by  an 
inflammatory  areola  and  the  pustules  are  umbilicated.  The 
appearance  of  the  eruption  in  smallpox  is  attended  with  a  fall 
in  the  temperature ;  in  varicella,  the  temperature,  rarely  high, 
is  uninfluenced  by  the  appearance  of  the  rash.  Varicella  is  a 
disease  of  scarcely  a  week;  smallpox  is  a  disease  of  three 
weeks.    JSTeither  is  protective  against  the  other. 

How  are  varicella  and  varioloid  to  be  differentiated? 

There  may  be  a  close  similarity  between  the  manifestations 
of  varicella  and  those  of  varioloid.  Varicella  is  rare  in  adults 
because  of  the  immunity  conferred  by  an  attack  in  childhood. 
Varioloid  does  not  respect  age  ;  it  is  likely  to  appear  in  the  course 
of  an  epidemic  of  variola  in  those  that  have  been  protected  by 
vaccination.     Varicella  is  the  milder  affection,  and  is  of  the 


80  ESSENTIALS    OF    DIAGNOSIS. 

shorter  duration.  Varioloid  is  but  an  attenuation  and  abbrevia- 
.  tion  of  variola.  Both  varicella  and  varioloid  are  contagious. 
The  existence  of  parallel  cases  may  be  decisive  in  diagnosis. 
An  attack  of  the  one  does  not  protect  against  invasion  by  the 
other. 

How  are  varicella  and  morbilli  to  be  differentiated  ? 

The  eruption  of  measles  is  coarsely  papular  ;  it  appears  on  the 
third  or  fourth  day  and  displays  a  special  proclivity  to  invade 
the  face,  with  a  tendency  to  crescentic  arrangement.  The  erup- 
tion of  chickenpox  is  at  first  papular  and  subsequently  vesicular  ; 
it  appears  on  the  first  or  second  day  and  is  rather  less  than 
more  abundant  on  the  face  than  on  the  trunk.  The  catarrhal 
symptoms  of  measles  are  wanting  in  varicella.  The  tempera- 
ture-course is  not  characteristic  in  varicella,  as  it  is  in  measles. 

Erysipelas. 

What  are  the  symptoms  of  erysipelas  ? 

Erysipelas  is  an  acute  contagious  disease,  depending  upon  the 
activity  of  a  streptococcus,  and  occurring  most  commonly  in 
the  spring.  The  period  of  incubation  is  from  three  to  seven 
days.  The  disease  usually  sets  in  suddenly  with  a  chill,  some- 
times with  nausea  and  vomiting,  or  with  convulsions,  followed 
by  considerable  elevation  of  temperature,  and  the  appearance, 
usually  at  some  part  of  the  face,  and  in  most  instances  near  one 
or  other  ear,  or  on  the  bridge  of  the  nose,  of  an  area  of  red, 
brawny  induration.  The  redness  progressively  increases  in  ex- 
tent, is  definitely  circumscribed  by  an  elevated  line  of  demarca- 
tion, and  is  attended  with  swelling. 

The  appetite  is  impaired.     The  tongue  is  coated. 

The  urine  is  usually  albuminous,  and  often  contains  tube-casts, 
sometimes  leucin  and  tyrosin.  The  number  of  colorless  blood- 
corpuscles  is  increased. 

There  is  often  some  soreness  of  the  throat,  and  in  some  cases 
the  disease  may  extend  through  the  nasal  passages  into  the 
pharynx  and  larynx,  causing  grave  complications,  and,  perhaps, 
fatal  edema.     Sometimes  the  disease  begins  in  the  throat. 

Involvement  of  a  cerebral  sinus  may  occur,  giving  rise  to 


ERYSIPELAS.  81 

severe  symptoms  and  eventually  causing  death.  Suppuration 
is  not  uncommon. 

Usually,  in  the  course  of  a  week  or  ten  days,  the  redness  and 
swelling  subside,  desquamation  sets  in,  and  the  temperature 
gradually  reaches  the  normal. 

In  some  cases  the  disease  displays  a  migratory  tendency 
{erysipelas  migrans),  continuing  for  a  long  period  of  time,  and  in 
turn  appearing  at  various  parts  of  the  body.  In  children,  ery- 
sipelas sometimes  appears  first  in  the  neighborhood  of  the  amis. 
The  disease  often  attacks  wounds.  Recurrence  is  not  uncom- 
mon. 

What  are  the  differential  features  between  erysipelas  and 
scarlatina  ? 

Scarlatina  is  especially  a  disease  of  childhood.  Erysipelas  is 
more  common  in  adults  than  in  children. 

The  temperature  is  high  in  both,  but  the  rapidity  of  the  pulse 
is  the  more  characteristic  of  scarlatina. 

The  rash  of  erysipelas  is  circumscribed  in  extent,  limited  in 
area,  homogeneous  in  color  ;  it  usually  appears  upon  the  face, 
and  presents  a  peculiar  brawny  induration,  with  well-defined 
borders  ;  while  the  eruption  of  scarlatina  is  extensive  in  distri- 
bution and  punctate  in  character. 

An  attack  of  scarlatina  confers  immunity  from  subsequent 
attacks ;  one  attack  of  erysipelas  rather  predisposes  to  the  oc- 
currence of  subsequent  attacks. 

Of  the  two,  scarlet  fever  is  the  longer  in  duration. 

How  does  erysipelas  differ  from  simple  erythema  ? 

Simple  erythema  presents  a  diffuse  redness,  of  transitory  char- 
acter, without  febrile  concomitants  or  sequelae. 

Erysipelas  is  a  serious  affection,  with  considerable  elevation 
of  temperature  and  characteristic  rapidity  of  pulse.  It  lasts  a 
week  or  more,  is  followed  by  desquamation,  and  is  intimately 
related  with  nephritis. 

How  are  facial  erysipelas  and  herpes  zoster  of  the  forehead  and 

face  to  be  differentiated  ? 
Eacial  erysipelas  and  herpes  zoster  of  the  forehead  and  face 
present  a  number  of  symptoms  in  common.     That  which  dis- 

6 


82  ESSENTIALS    OF    DIAGNOSIS. 

tingiiisbes  the  latter,  however,  is  that  the  eruption  begins  as  a 
number  of  vesicles  and  does  not  extend  beyond  the  middle  line. 
The  pain  is  much  greater  in  herpes  than  in  erysipelas.  The 
constitutional  symptoms  are  more  profound  in  erysipelas  than 
in  herpes. 

How  are  variola  and  erysipelas  to  be  differentiated  ? 

When  variola  is  attended  with  a  ])rimary  roseola,  the  disease 
may,  for  several  days,  simulate  erysipelas.  The  redness  of 
erysipelas,  however,  is  distinctly  circumscribed,  although  it  may 
slowly  spread,  and  is  attended  with  brawny  induration,  while 
that  of  smallpox  rapidly  spreads  from  the  face  to  the  trunk  and 
extremities.  On  the  third  or  fourth  day,  if  the  disease  is 
variola,  papules  appear,  progressively  passing  through  the 
stages  of  vesicles  and  pustules.  The  eruption  of  erysipelas  un- 
dergoes little  change,  unless  large  blebs  form,  until  on  about  the 
fifth  or  seventh  day,  when  it  may  subside  with  desquamation. 

Glandular  Fever. 

What  is  glandular  fever  ? 

Glandular  fever  is  probably  an  infectious  disease,  occurring 
especially  in  children,  and  attended  with  redness  of  the  throat 
and  enlargement  of  the  cervical  lymph-glands. 

What  is  the  symptomatology  of  glandular  fever  ? 

The  disease  sets  in  suddenly,  with  pain  on  movement  of  the 
head  and  neck.  The  temperature  is  slightly  elevated,  and 
there  may  be  nausea,  vomiting  and  abdominal  pain.  Slight 
redness  of  the  throat  is  visible  and  sometimes  also  the  axillary 
and  the  cervical,  the  inguinal  and  the  mesenteric  lymphatic 
glands  become  enlarged  and  somewhat  tender.  In  many  cases 
liver  and  spleen  also  are  enlarged.  The  adenitis  may  persist 
for  several  weeks.     Suppuration  may  take  place. 

Miliaria— Miliary  Fever— Sweating  Disease. 

What  is  miliary  fever  ? 

Miliaria  is  probably  an  infectious  disease  characterized  by  a 


DENGUE.  83 

vesicular  eruption  and  excessive  sweating.  There  may  be, 
besides,  gastric  disturbance  and  general  malaise,  and  in  severe 
cases  high  fever,  delirium,  prostration  and  hemorrhage.  The 
eruption  appears  on  about  the  fourth  day,  and  is  attended  with 
itching  and  an  aggravation  of  existing  symptoms. 

Dengue, 

What  are  the  symptoms  of  dengue  or  "  break-bone  fever  ? " 

Dengue  is  an  exauthematous  and  arthritic  disease  of  hot 
climates,  occurring  in  epidemics^  and  having  a  xjeriod  of  incu- 
bation of  about  four  days.  It  is  characterized  by  a  peculiar 
intermittent  temperature-course  and  by  severe  pains  in  the 
muscles  and  joints,  which  latter  may  be  stiff  and  swollen.  The 
knees  are  especially  prone  to  be  affected,  so  that  the  gait  pre- 
sents a  peculiar  character.  A  micrococcus  has  been  described 
as  present  in  the  blood.  The  disease  may  be  gradual  in  onset, 
with  anorexia,  headache,  vertigo,  drowsiness,  or  it  may  set  in 
suddenly  with  a  chill,  moderate  elevation  of  temperature  and 
the  appearance  of  an  erythematous  rash.  There  are  stiffness 
of  the  neck  and  pain  along  the  spine  and  in  the  lumbar  region. 
The  fever  reaches  its  acme  within  twenty-four  hours.  The  tem- 
perature  fluctuates,  rising  and  falling,  but  in  the  course  of  two 
or  three  days  subsides  nearly  or  quite  to  the  normal ;  the  erup- 
tion disappears,  though  constitutional  depression  and  more  or 
less  pain  continue.  As  a  rule,  nausea  and  vomiting  do  not 
occur  at  this  stage,  though  the  tongue  may  be  heavily  coated, 
and  there  may  be  other  symptoms  of  gastric  irritability. 

After  an  intermittence  of  from  forty-eight  to  seventy -two  hours 
or  more,  the  fever  returns  and  a  new  eruption  appears,  as  a  rule 
resembling  the  eruption  of  scarlatina.  Sometimes  the  eruption 
is  more  like  that  of  measles,  or  it  may  be  urticarious  or  ves- 
icular. It  is  attended  with  heat  and  itching.  Nausea  and 
vomiting  are  usually  manifested  with  this  renewal  of  the  fever. 

In  the  course  of  a  few  days,  desquamation  occurs  ;  conva- 
lescence sets  in,  but  is  tard}?^  and  protracted  ;  there  is  weak- 
ness and  more  or  less  rheumatoid  muscular  pain  ;  lymphatic 
swellings  in  the  neck,  groin  or  axilla  often  appear  during  the 


84  ESSENTIALS    OF   DIAGNOSIS. 

febrile  period  or  during  convalescence.    When  the  disease  in- 
vades a  community,  few  escape. 

How  does  dengue  differ  from  scarlatina  with  arthritic  mani- 
festations ? 
In  dengue  the  fever  is  not  continuous  and  pursues  a  course 
different  from  that  of  scarlatina;  the  arthritic  symptoms  are  of 
earlier  occurrence,  and  the  pain  is  of  a  characteristic  nature, 
giving  the  name  "break-bone"  fever.  The  eruption  develops 
much  later,  and  is  sometimes  quite  different  in  appearance  from 
that  of  scarlatina.  The  erythematous  rash  of  the  period  of  in- 
vasion is  slight,  inconstant  and  disappears  without  desquama- 
tion when  the  remission  or  intermission  occurs.  Throat-symp- 
toms are  not  common. 

In  what  respect  does  dengue  differ  from  influenza  ? 

Influenza  is  the  graver  disease  ;  its  symptoms  are  the  more 
intense. 

Catarrhal  symptoms  are  frequent  in  influenza,  infrequent  in 

dengue. 

Eruptions  are  exceptional  in  influenza,  the  rule  in  dengue. 

Joint-pains  are  more  decided  in  dengue.  Hyperesthesia  of 
the  cutaneous  surface  is  more  common  in  influenza. 

The  course  of  dengue  is  interrupted  by  a  remission.  The 
course  of  influenza  is  usually  though  not  invariably  continuous 
to  its  termination. 

Influenza  is  independent  of  climate.  Dengue  prevails  only  in 
certain  localities.  Convalescence  is  even  more  tedious  and 
protracted  from  dengue  than  from  influenza. 

Diphtheria, 

What  are  the  symptoms  of  diphtheria  ? 

Diphtheria  is  an  acute,  contagious  disease  affecting  children 
especially,  but  adults  as  well,  and  characterized  by  superficial 
coagulation-necrosis  of  mucous  membranes,  especially  of  those 
of  the  pharynx,  larynx  and  nares,  with  symptoms  of  constitu- 
tional intoxication.  It  is  dependent  upon  the  activity  of  the 
Klebs-Lofiler  bacillus,  which  is  found  in  the  false  membrane 


DIPHTHERIA.  85 

and  at  the  site  of  the  disease,  and  which  varies  considerably  in 
virulence.  The  conjunctiva,  the  ear  and  the  external  integu- 
ment also  may  be  attacked.  The  period  of  incubation  is  from 
two  to  seven  days. 

The  attack  may  begin  insidiously,  or  set  in  suddenly  with  a 
chill,  followed  by  considerable  fever. 

Pain  in  the  throat  in  swallowing  may  or  may  not  be  com- 
plained of.  The  fauces  will  be  seen  to  be  livid,  the  tonsils 
usually  swollen. 

Soon,  there  appear,  in  greater  or  less  extent  and  rapidly 
spreading  over  the  tonsils,  the  half-arches,  the  uvula  and  the 
posterior  wall  of  the  pharynx,  grayish  or  yellowish  patches  of 
false  membrane,  the  forcible  detachment  of  which  is  followed 
by  bleeding.  There  are  enlargement  of  the  submaxillary  and 
cervical  glands  and  tumefaction  of  the  soft  tissues  of  the  neck, 
externally.     The  number  of  colorless  blood-corpuscles  is  increased. 

The  constitutional  disturbance  becomes  profound.  Albumin- 
uria is  common.  From  the  pharynx  the  inflammation  and 
necrosis  may  extend  to  the  larynx  and  to  the  nose,  and  to  the 
difliculty  of  swallowing  are  added  croup}'  cough,  aphonia,  diffi- 
culty of  breathing  and  a  nasal  discharge.  The  diphtheritic 
process  is  sometimes  primary  in  the  nose,  and  may  thus  escape 
detection,  unless  careful  examination  be  made.  From  the 
larynx  the  false  membrane  may  invade  the  trachea  and  bronchi. 
Pneumonia  may  occur.  The  action  of  the  hea.rt  becomes  weak 
and  often  intermittent.  Septicemia,  heart-failure  and  suffoca- 
tion from  obstruction  of  the  larynx  or  bronchi  are  the  common 
causes  of  death. 

The  fatality  of  the  disease  varies  in  different  epidemics.  Even 
in  times  of  grave  epidemics,  there  are  many  mild  cases  that 
become  foci  of  infection.  Chronic  dipMlieria  of  the  throat  is  not 
so  rare  as  it  is  commonly  considered  to  be  and  is  likewise  a 
focus  of  infection.  Paralysis  from  peripheral  neuritis  or  cere- 
bral thrombosis  may  be  a  sequel. 

The  palsy  of  diphtheria  may  appear  in  the  course  of  the  dis- 
ease, but  it  is  more  common  after  the  acute  attack  is  at  an  end. 
Adults  are  rather  more  prone  to  suffer  than  children.  The 
most  common  manifestations  are  pjaralysis  of  the  X)(idate^  permit- 


86  ESSENTIALS    OF    DIAGNOSIS. 

ting  regurgitation  of  fluids  and  giving  rise  to  nasal  speech ; 
paralysis  of  the  ciliary  muscle  (cycloplegla),  causing  loss  of  power 
of  accommodation ;  loss  of  knee-jerl-s.  There  may  be  more 
general  palsy,  with  deranged  sensation,  ataxia  and  trophic 
changes. 

How  are  diphtheria  and  scarlatina  to  be  differentiated  ? 

At  the  onset,  tlie  diseases  may  be  indistinguishable.  Both 
present  the  evidences  of  constitutional  disturbance,  with  local- 
ized throat-symptoms.  Possibly,  the  pulse  may  be  relatively 
more  rapid  in  scarlatina  than  in  diphtheria.  In  from  twenty- 
four  to  thirty-six  hours,  however,  the  appearance  of  a  scarlet 
rash,  as  well  as  the  subsequent  course  of  the  disease,  dispels 
all  doubt.  In  diphtheria,  the  symptoms  centralize  themselves 
about  the  throat ;  in  scarlatina  the  throat-disturbance  represents 
but  a  part  of  the  general  derangement.  The  detection  of  diph- 
theria-bacilli in  the  false  membrane  removes  all  doubt.  The 
paralyses  commonly  seen  after  diphtheria  are  rare  after  scarla- 
tina. More  common  during  the  course  of  scarlet  fever  or  sub- 
sequently are  suppurative  ear-disease,  nephritis  and  glandular 
enlargement. 

Diphtheria  and  scarlatina  may  coexist  in  the  same  patient. 

How  is  tonsillitis  to  be  distinguished  from  diphtheria  ? 

Deposits  on  the  tonsil  may  appear  diphtheritic.  They  show 
little  or  no  tendency  to  spread,  however.  Extension  is  charac- 
teristic of  the  diphtheritic  membrane.  In  lacunal  tonsilUtis, 
the  discreteness  of  the  plugs  and  their  situation  at  the  orifices 
of  the  ducts  are  characteristic,  and  their  creamy  color  is  differ- 
ent from  that  of  the  diphtheritic  pseudomembrane.  Microsco- 
pically, they  will  be  seen  to  be  made  up  of  desquamated  epi- 
thelium, of  sebaceous  material  and  of  ordinary  fungi.  The 
diphtheric  membrane  is  constituted  of  meshes  of  fibrin  includ- 
ing necrotic  tissue,  and  it  contains  diphtheria-bacilli.  In  her- 
petic tonsillitis  the  eruption  first  appears  as  papules  that  soon 
become  vesicles  ;  but  it  is  rarely  seen  at  this  stage  ;  when  ulcers 
and  fibrinous  deposits  form  and  become  confluent,  the  discrimi- 
nation is  difficult.  Still,  the  herpetic  patch  is  quite  superficial, 
and  more  readily  detached,  leaving  less  erosion  and  causing  less 


GLANDERS  —  FARCY  —  EQUINIA.  87 

hemorrhage  in  its  separation  than  does  the  diphtheric  patch. 
The  former  is  usually  the  less  extensive,  and  here  and  there, 
perhaps,  the  circular  form  of  an  isolated  ulcer  may  give  evi- 
dence of  its  origin.  If  necessary,  inoculation-experiments  and 
bacteriologic  investigation  will  also  help  to  discriminate.  The 
constitutional  symptoms  of  tonsillitis  are  less  profound  than 
those  of  diphtheria;  local  subjective  symptoms,  such  as  sore- 
ness, odynphagia  and  burning,  are  usually  the  more  intense  in 
tonsillitis,  which  is  not,  as  a  rule,  followed  by  paralysis  of  the 
palate.     Albuminura  is  not  usual. 

How  is  membranous  croup  to  he  distinguished  from  diph- 
theria ? 

Until  the  physician  acquires  sufficient  experience  to  warrant 
a  personal  opinion,  he  had  best  consider  all  cases  of  membran- 
ous croup  diphtheritic.  The  discrimination  is  difficult  and 
disputed. 

How  are  diphtheria  and  stomatitis  to  be  differentiated  ? 

The  deposits  in  stomatitis  are  seated  upon  the  mucous  surface 
of  the  lips  and  cheeks  and  upon  the  tongue,  while  the  mem- 
brane of  diphtheria  is  usually  seated  in  the  pharynx,  from 
which,  as  a  center,  it  is  distributed.  The  constitutional 
derangement  is  not  as  profound  in  stomatitis  as  in  diphtheria. 
Stomatitis  readily  yields  to  mild  general  and  local  measures, 
while  diphtheria  is  more  rebellious  to  treatment.  The  fatality 
and  the  severe  sequelae  of  diphtheria  are  wanting  in  stomatitis. 

Glanders— Farcy — Equinia. 

What  are  the  clinical  features  of  glanders  ? 

Glanders,  farcy  or  equinia  is  an  infectious  disease,  especially 
peculiar  to  horses,  asses,  and  mules,  from  which  it  is  trans- 
mitted to  man  through  abrasions  of  the  skin  and  through  the 
mucous  surfaces  of  those  that  come  in  contact  with  the  diseased 
animals. 

The  site  of  inoculation  displays  evidence  of  active  inflamma- 
tion ;  especially  is  this  marked  in  the  nasal  passages.  There  are 
also  malaise,  headache,  elevation  of  temperature  and  pains  in 


88  ESSENTIALS    OF    DIAGNOSIS. 

the  limbs  ;  the  urine  may  be  albuminous.  Soon  there  appears 
a  macular  eruption,  which  becomes  vesicular,  then  pustular 
and  finally  uml)ilicated.  The  pustules  may  rupture  and  leave 
ugly  ulcers.  It  is  dependent  upon  the  activity  of  a  short,  non- 
motile  bacillus.  The  disease  may  appear  in  an  acute  or  a 
chronic  form.  The  period  of  incubation  is  three  or  four  days. 
In  addition,  nodules  form  beneath  the  skin ;  these  also  soften 
and  may  rupture,  discharging  sanious  pus  and  detritus.  Lym- 
phatic glands  are  enlarged.  Another  characteristic  symptom 
of  glanders  is  ozena.  There  is  at  first  a  moderate,  thin  dis- 
charge from  the  nostrils,  soon,  however,  becoming  profuse  and 
purulent.  The  mucous  membrane  of  the  nares  and  contiguous 
structures  is  involved  in  intense  inflammation  and  may  become 
ulcerated.  Catarrhal  pneumonia  and  purulent  arthritis  are 
occasional  complications.  Glanders  may  be  transmitted  from 
man  to  the  lower  animals  by  inoculation. 

How  are  glanders  and  variola  to  be  differentiated  ? 

In  glanders,  there  may  be  a  history  with  the  local  evidences 
of  inoculation  with  the  specific  virus  of  the  disease.  The 
eruption  of  variola  does  not  appear  until  the  third  or  fourth 
day  ;  with  its  appearance  the  temperature  falls.  The  eruption 
of  glanders  may  appear  within  the  first  twenty-four  or  forty- 
eight  hours  of  the  disease  ;  it  reaches  a  pustular  stage  much 
earlier  than  that  of  variola  ;  there  is  no  decline  of  temperature 
with  its  appearance.  The  ozena  and  the  subcutaneous  nodules 
of  glanders  are  wanting  in  variola. 

How  are  the  ozena  of  glanders  and  that  of  syphilitic  disease  to 
be  differentiated  ? 

Ozena  is  dependent  upon  destruction  of  the  nasal  structures 
and  putrefactive  decomposition  of  the  secretions.  It  is  thus  not 
distinctive  of  a  single  disease.  Occurring  in  syphilis,  it  is  a  late 
manifestation,  and  probably  has  been  preceded  by  well-defined 
symptoms.  As  seen  in  glanders,  it  occurs  at  the  height  of  the 
disease,  and  is  associated  with  a  pustular  eruption  and  the 
presence  of  nodules  beneath  the  skin.  The  mode  of  infection 
differs  in  the  two  diseases. 


ANTHRAX  —  wool-sorters'    DISEASE.  89 


Anthrax — Wool-sorters'  Disease. 

What  are  the  clinical  features  of  anthrax  ? 

Anthrax^  loool-sorters'  or  brush-makers'  disease,  charbon,  malig- 
nant pustule  or  splenic  fever  is  an  infectious  disease,  due  to  inoc- 
ulation with  the  bacillus  anthracis.  (Fig.  14.)  It  develops  in 
butchers,  wool-sorters,  workers  in  hides,  stevedores,  and  others 
that,  with  cut  or  wounded  or  abraded  hands,  manipulate  the 
wool,  hair  or  skins  of  animals  that  have  died  of  splenic  fever 
or  charbon.  The  infection  sometimes  gains  entrance  through 
a  scratch  on  the  cheek  or  an  abrasion  of  the  lips.  In  butchers, 
the  tongue  is  sometimes  infected  from  a  knife  taken  between 
the  teeth.  In  those  that  carry  hides  upon  their  shoulders,  the 
neck  may  be  the  site  of  local  infection ;  these  cases  are  likely 
to  be  more  than  ordinarily  dangerous.  The  disease  may  ap- 
parently result  from  eating  the  flesh  or  from  drinking  the  milk 
of  infected  animals. 

Fig.  14. 


Anthrax  bacilli  in  blood.     (Vierordt.) 

At  the  site  of  inoculation,  a  pimple  appears  ;  the  skin  in  its 
neighborhood  becomes  red  and  infiltrated  ;  the  papule  becomes 
vesicular  and  pustular,  with  subsequent  gangrene  ;  other  vesi- 
cles or  pustules  form  and  also  become  gangrenous ;  there 
results  a  characteristic  eschar,  which  presents  the  appearance 
of  an  elevated  patch,  consisting  of  a  zone  of  low,  whitish  vesicles 


90  ESSENTIALS    OF    DIAGNOSIS. 

surrounding  a  depressed  brownish,  purplish,  or  black  center, 
with  an  outer  zone  of  red  induration.  Beyond  this  is  usually 
a  region  of  swellinc:  and  edema  of  variable  extent.  The 
spleen  and  the  lymphatic  glands  in  communication  with  the 
infected  regions  enlarge.  There  is  often  considerable  local 
tenderness.  The  cmistitutional  symjAoms  are  those  of  septico- 
pyemia :  malaise,  headache,  depression,  fever.  According  to 
the  mode  of  introduction  of  the  poison,  or  the  direction  in 
which  infection  spreads,  other  manifestations  appear.  Some- 
times the  gastro-intestinai  tract  appears  to  bear  the  brunt  of  the 
disease  and  there  are  nausea,  vomiting,  abdominal  pains  and 
diarrhea,  the  stools  being  bloody.  Death  may  take  place  from 
exhaustion  or  from  septicemia.  At  other  times,  thoracic  symp- 
toms predominate.  There  are  then  dyspnea,  a  sense  of  oppression 
of  breathing,  hemoptysis  and  cyanosis.  Death  may  take  place 
from  edema  of  the  larynx  or  of  the  mediastinum.  Charac- 
teristic bacilli  may  often  be  found  in  the  blood,  pus,  sputum, 
feces,  or  urine.  Under  proper  treatment  recovery  frequently 
takes  place. 

Actinomycosis. 

What  is  actinomycosis  ? 

Actinomycosis  is  a  condition  dependent  upon  the  presence  of 
ray-fungi :  actinomyces  hovis.     (Fig.  15.)    The  disease  is  more  fre- 


Acfinomyces.    (Ziegler.) 


quent  in  drovers  and  in  those  that  have  to  do  with  cattle,  from 
which  the  parasite,  as  found  in  man,  is  usually  derived.     The 


FOOT-AND-MOUTH    DISEASE  —  MILK-SICKNESS.       91 

cattle  become  infected  through  their  food.  The  fungus  gains 
entrance  through  a  breach  in  continuity  of  the  surface  and,  finding 
its  way  to  a  suitable  nidus,  gives  rise  to  the  formation  of  a  sero- 
purulent  collection  ;  this  manifests  itself  as  a  tumor  that  usually 
finds  vent  externally.  In  the  matter  discharged,  yellowish  mili- 
ary nodules,  composed  of  fungi,  can  be  detected.  The  lower  jaw 
seems  to  be  a  favorite  seat  of  the  disease,  infection  taking  place 
through  decayed  teeth  ;  sometimes  extensive  destruction  of  bone 
results.  At  other  times,  purulent  collections  form  in  internal 
viscera.  The  intestinal  tract,  the  lungs,  the  skin,  the  brain,  may 
be  the  seat  of  the  disease.  When  the  pleura  is  infected  the  ribs 
may  suffer  severely.  The  symptoms  vary  with  the  localization 
of  the  morbid  process. 


Foot-and-Mouth  Disease. 

What  is  foot-and-mouth  disease  ? 

Foot-and-mouth  disease  is  a  rare  affection  that  occurs  in  sheep, 
cows,  pigs  and  horses,  and  that  occasionally  seems  to  be  trans- 
mitted to  man.  It  manifests  itself  by  the  appearance  of  vesicles 
and  bullae  in  the  mouth  and  on  the  feet  at  the  margins  of  the 
hoofs  and,  in  cows,  on  the  udder  and  teats.  The  disease  ma}^ 
be  transferred  directly  to  man  by  inoculation — thus  to  the 
butcher  or  to  the  veterinary  surgeon,  or  it  may  be  conveyed  by 
milk.  In  man,  vesicles  form  in  the  mouth,  on  the  face,  on  the 
hands  and  on  the  feet.  In  the  course  of  two  or  three  days, 
the  vesicles  rupture,  discharging  opaque,  yellowish  fluid,  and 
leaving  dark-red  ulcers.  There  are  also  fever,  loss  of  appetite, 
pain  in  eating,  swelling  ■  of  the  tongue,  fetor  of  the  breath, 
salivation  and  derangement  of  digestion.  In  children  the  dis- 
ease may  prove  fatal. 

Milk-Sickness. 

What  is  milk-sickness  ? 

This  affection  is  probably  a  form  of  food-poisoning,  arising  in 
human  beings  who  have  partaken  of  the  flesh  or  the  milk  (or 


92 


ESSENTIALS    OF    DIAGNOSIS 


its  products,  butter  and  cheese)  derived  from  animals  suffering 
from  a  disorder  known  as  trembles. 

What  are  the  symptoms  of  milk-sickness  ? 

There  is  complaint  of  a  sense  of  fatigue  and  languor,  with 
headache,  thirst,  loss  of  appetite,  nausea,  vomiting,  pyrosis, 
epigastric  pain  and  constipation.  The  breath  is  peculiarly 
offensive ;  the  skin  is  dry,  the  tongue  moist  and  coated.  Res- 
piration is  labored  and  sighing  ;  the  temperature  is  not  elevated 
and  may  be  subnormal ;  the  pulse  is  not  accelerated.  Prostra- 
tion may  progress  to  coma  and  death  within  a  few  days.  Con- 
valescence is  tardy  and  may  prolong  the  illness  for  several 
weeks. 

Hydatid  (Echinococcus)  Disease. 

What  is  hydatid  disease  ? 

An  hydatid  cyst  is  a  parasitic  formation  due  to  ingestion  of 
the  ova  of  the  tenia  echinococcus^  the  tape-worm  of  dogs,  in  which 
it  is  derived  from  the  flesh  of  sheep,  or  pigs,  or  less  frequently, 
kine,  suffering  from  hydatid  disease. 

Fig.  16. 


'^ 


Tenia  Echinococcus— vesicle,  scolex  and  hooks.    (After  Heller.) 

When  the  ovum  enters  the  stomach  of  man,  its  capsule  is 
dissolved,  and  the  immature  embryo  or  scolex  (Fig.  16)  is  set 
free  to  continue  its  migrations.  Arriving  at  its  destination, 
the  irritation  to  wdiich  it  gives  rise  results  in  the  formation  of 
a  membranous  envelop,  in  which  the  parasite  continues  its  de- 
velopment.    This  capsule,  and  its  contents  together  constitute 


TRICHINIASIS.  93 

an  hydatid  cyst.  An  hydatid  cyst  contains  within  the  capsule,  a 
vesicle  or  mother-sac,  consisting  of  concentric  layers  of  a  gelatin- 
ous material,  inclosing  the  embryo  and  more  or  less  fluid. 
The  fluid  is  clear,  opalescent,  and  faintly  alkaline.  Within 
this  develop  other  similar  sacs,  so-called  daughter-vesicles,  and 
within  these  again,  granddaughter-vesicles ;  the  mother-sac 
and  its  investing  membrane  continue  to  enlarge,  if  in  a  favor- 
able situation,  until  ultimately  the  cyst  attains  an  enormous 
size.  Multiple  cysts  may  form.  The  daughter-vesicles  contain 
a  germinating  layer  that  produces  new  scolices.  These  con- 
sist of  a  head,  four  suckers  and  a  row  of  booklets.  The  dis- 
covery of  the  booklets  (Fig.  16)  in  fluid  removed  from  the  cyst 
is  diagnostic.  Sterile  echinococd  or  acephalnrysts  do  not  produce 
scolices.  The  cysts  may  perforate  into  adjacent  organs,  rupture 
externally  or  undergo  suppuration. 

Hydatids  may  develop  in  various  viscera,  but  are  most  com- 
mon in  the  liver ;  then  in  order  of  frequency  follow  the  genito- 
urinary system,  the  intestinal  canal,  the  lungs  and  pleura,  the 
brain  and  spinal  canal. 

The  symptoms  are  those  of  a  cystic  tumor  and  varj'  with  the 
size  and  situation  of  the  formation.  When  superficial  the  cyst 
may  yield  on  palpation  and  percussion  a  peculiar  vibratile 
tremor  or  fremitus.  When  perforation  or  rupture  takes  place, 
or  on  exploratory  puncture,  the  characteristic  booklets  may  be 
detected  in  the  fluid  obtained.  In  the  event  of  suppuration 
chills,  fever,  and  other  symptoms  may  appear. 

Trichiniasis. 

What  is  trichiniasis  ? 

Trichiniasis  is  a  disease  set  up  by  the  trichina  spiralis  (Fig. 
17),  a  small  roundworm  that  finds  its  way  into  the  intestine  with 
meat  obtained  from  diseased  swine. 

In  the  intestine  the  mature  female  throws  off"  embryos,  which 
pass  through  the  w^alls  of  the  intestine  and  into  the  blood-cur- 
rent, finding  their  way  into  the  voluntary  muscles  in  different 
parts  of  the  body.  Here  the  embryos  occasion  irritation  and 
inflammation,  so  that  about  each  a  capsule  forms  in  which 


94 


ESSENTIALS    OF    DIAGNOSIS. 


lime-salts  are  in  time  deposited  ;  in  this  way  the  death  of  the 
eml)ryo  may  be  brought  about. 

What  are  the  symptoms  of  trichiniasis  ? 

The    symptoms     of  trichiniasis  present 
Fig.  17.  themselves  in   three   stagea.      In   the  jirst^ 

which  lasts  about  a  week,  the  trichinse  are 
undergoing  development  in  the  alimentary 
canal,  as  a  result  of  which  the  symptoms  of 
gastro-intestinal  derangement  appear.  In 
the  second  stage,  lasting  two  or  three 
weeks,  the  embryos  pass  from  the  intestine 
into  the  muscular  tissue.  Finally,  retro- 
gressive changes  take  place  in  and  around 
the  trichinae  encapsulated  in  the  muscles. 

In  the  first  stage,  the  appetite  is  im- 
paired ;  the  tongue  is  coated,  the  breath 
is  foul ;  there  are  malaise,  nausea,  a  bad 
taste,  diarrhea,  abdominal  pain  and  slight 
fever.  Leukocytosis  is  marked,  the  esino- 
phile  cells  being  especially  increased  in 
number. 

In  the  second  stage,  there  is  edema,  ap- 
parent in  the  face  and  sometimes  extending 
downward ;  there  are  also  pains  in  the 
muscles,  which  are  swollen ;  defects  of  the 
ocular  muscles  and  of  accommodation  some- 
times appear ;  the  senses  and  various  func- 
tions may  be  affected ;  sleep  is  disturbed 
and  there  is  moderate  fever.  The  muscles 
are  sensitive  to  touch,  which  may  detect  the  minute  nodules. 
Death  may  result  from  exhaustion,  pneumonia  or  ulceration  of 
the  bowel.  In  favorable  cases,  the  symptoms  gradually  subside 
and  the  patient  enters  upon  the  third  stage  of  the  disease. 
Active  symptoms  are  now  in  abeyance,  but  there  may  be  some 
stiffness  of  the  muscles,  while  noduless  in  the  muscles  may  be 
detectable. 

Ultimately,  however,  the  patient  may  be  restored  to  a  fair 
degree  of  health. 


Trichina,  a,  Male  ;  b, 
Female  ;  c,  Muscle-Tri- 
china.    (V.  Jaksch ) 


FILARIASIS DRACONTIASIS.  95 

Filariasis. 

What  is  filariasis  ? 

Filariasis  is  a  condition  arising  from  the  presence  in  the 
lymph  or  the  blood  of  the  filar  la,  sanguinis  hominis,  a  nematode 
parasite,  from  3  to  4  inches  in  length,  that  periodically  dis- 
charges its  ova  into  the  circulation.  By  obstruction  there  may 
result  hematochyliiria,  lymph- scrotum  and  elephantiasis. 

Dracontiasis. 

What  is  dracontiasis? 

Dracontiasis  is  a  condition  arising  from  the  invasion  of  the 
filaria  or  dracunculus  medinensis  (Guinea-worm),  a  parasite  from 
20  to  40  inches  in  length,  that  gains  entrance  through  the 
stomach,  the  impregnated  female  penetrating  the  intestine  and 
finding  its  way  to  the  subcutaneous  and  intermuscular  connect- 
ive tissue,  where  it  gives  rise  to  the  formation  of  a  vesicle  that 
ruptures  and  leaves  an  ulcer. 

Acute  Rheumatism — Rheumatic  Fever. 

What  are  the  symptoms  of  acute  rheumatism  ? 

Acute  rheumatism  or  rheumatic  fever  usually  follows  ex- 
posure to  cold.  An  almost  identical  condition  is  sometimes 
observed  in  the  course  of  puerperal  fever  and  as  a  sequel  of 
scarlatina.  It  has  been  thought  to  be  dependent  upon  the 
presence  of  lactic  acid  in  the  blood.  It  is  probable  that  the 
disorder  is  of  bacterial  origin,  though  the  evidence  is  not  yet 
conclusive.  The  disorder  prevails  most  in  temperate  and 
humid  climates,  and  young  adult  males  are  most  commonly 
affected. 

The  onset  is  generally  abrupt,  one  of  the  larger  joints  becoming 
painful,  enlarged,  hot  and  reddened.  It  is  evidently  inflamed  ; 
sometimes  the  presence  of  fluid  can  be  detected.  Soon,  another 
joint,  probably  the  corresponding  joiiit  on  the  opposite  side,  or 
the  next  contiguous  joint,  becomes  similarly  involved  ;  and  in 
this  way  the  process  may  extend,  until  most  or  all  of  the  large 


96  ESSENTIALS    OF    DIAGNOSIS. 

joints  are  in  turn  attacked.  On  account  of  the  pain,  the  patient 
is  immovably  helpless.  From  the  surflice  of  the  body  exudes 
an  acid  sweat.  The  temperature  ordinarily  ranges  from  102°  F. 
to  104°  F.,  rising  with  each  fresh  access  of  joint-symptoms,  and 
declining  gradually  with  the  termination  of  the  disease.  The 
pulse  is  disproportionately  frequent  ;  it  may  be  full  and  bound- 
ing. The  urine  is  scanty,  high-colored,  and  quite  acid  ;  it  may 
contain  a  trace  of  albumin.     Leukocytosis  is  marked. 

In  many  cases,  to  the  articular  manifestations  endocarditis  is 
added,  as  a  result  of  which  permanent  valvular  lesions  may  be 
established.  Among  other  complications  are  inflammations  of 
the  pericardium,  the  pleura,  the  peritoneum,  the  kidney,  the 
iris,  and,  though  rarely,  the  cerebro-spinal  meninges.  As  a 
rule,  delirium  is  due  to  the  toxemia  and  not  to  meningitis. 

Sometimes  the  temperature  rises  even  to  hyperpyrexia^  and 
there  are  decided  cerebral  symptoms— delirium,  convulsions, 
coma,  death. 

Untreated,  the  duration  of  acute  rheumatism  is  about  six 
weeks  ;  sometimes  much  longer.  Relapses  are  not  uncommon. 
An  attack  predisposes  to  subsequent  attacks. 

Furpmra  is  sometimes  seen  in  the  course  of  rheumatism  ; 
sometimes  tuberculated  cutaneous  nodules. 

In  some  cases  of  rheumatism,  hereditary  influences  can  be 
traced.  Some  authorities  consider  the  disease  a  dyscrasia,  others 
a  neurosis.  There  appears  to  be  an  indefinable,  yet  close  relation 
between  acute  rheumatism  and  chorea. 

Articular  rheumatism  not  uncommonly  accompanies,  pre- 
cedes or  follows  acute  tonsillitis.  In  cases  in  which  joint- 
involvement  is  insignificant  or  absent,  pericarditis  and  endo- 
carditis may  sometimes  be  detected  if  carefully  searched  for. 

How  are  pyemia  and  acute  rheumatism  to  be  differentiated  ? 

Both  pyemia  and  acute  rheumatism  occasion  arthritis,  sweats, 
cardiac  complications  and  cerebral  symptoms.  Periodicity  and 
rigors,  as  well  as  metastatic  invasion  of  internal  structures  re- 
mote from  the  primary  seat  of  disease,  which  are  common  in 
pyemia,  are  wanting  in  rheumatism.  The  constitutional  de- 
pression is  more  profound  in  pyemia  than  in  rheumatism.  In 
one,  an  obvious  or  obscure  focus  of  suppuration  exists  ;  in  the 


SYPHILITIC    ARTHRITIS.  97 

other,  there  is  a  history  of  rather  abrupt  onset  following  ex- 
posure to  cold  or  wet. 

How  are  acute  synovitis  and  acute  rheumatism  to  be  differ- 
entiated ? 

Acute  synovitis  usually  involves  but  a  single  joint ;  it  is 
characteristic  of  acute  rheumatism  to  progressively  attack 
many  joints.  The  constitutional  phenomena  are  more  profound 
in  acute  rheumatism  than  in  acute  synovitis. 

The  peculiar,  acid  sweats,  as  well  as  the  cardiac  complications 
of  rheumatism,  are  not  seen  in  synovitis. 

In  duration,  synovitis  is  the  shorter  disease. 

Gonorrheal  Synovitis, 

What  is  gonorrheal  synovitis  ? 

Occasionally,  in  the  course  of  an  attack  of  gonorrhea,  a  large 
joint — and  usually  but  one  joint,  such  as  the  knee,  the  elbow, 
the  wrist,  the  ankle  or  the  shoulder,  becomes  tumid,  painful, 
tender  and  hot,  and  the  adjacent  textures  may  be  edematous. 
The  urethral  discharge  often  ceases  with  the  appearance  of  the 
synovitis.  In  successive  attacks  of  gonorrhea,  different  joints 
may  be  involved.  Permanent  stiffness  and  impaired  mobility 
constitute  a  common  sequel.  Cardiac  complications  have  been 
observed  in  some  cases  of  gonorrheal  synovitis.  The  diagnosis 
depends  upon  a  knowledge  of  the  existence  of  a  specific  ure- 
thritis. Sometimes,  the  course  of  the  temperature  is  suggestive 
of  a  pyemic  or  of  a  septic  condition. 

Syphilitic  Arthritis. 

What  is  syphilitic  arthritis  ? 

Every  now  and  then,  in  the  course  of  syphilis,  one  or  more 
joints  become  involved  in  inflammation,  with  all  of  the  character- 
istics of  an  arthritis.  The  discrimination  of  the  condition  de- 
pends upon  a  recognition  of  its  association  with  syphilis.  As  a 
rule,  cardiac  complications  are  wanting  in  syphilis,  and  the 
arthritis  is  more  strictly  limited  to  one,  or  at  most,  two  joints, 
the  migratory  tendency  of  acute  articular  rheumatism  being 
absent. 

7    . 


98  ESSENTIALS    OF    I)  I  A  (i  N  (^  S  I  S  . 

Subacute  Rheumatism. 

What  is  subacute  rheumatism  ? 

At  times,  as  a  result  of  exposure  to  cold  and  wet,  muscular 
movement  becomes  painful,  in  consequence  of  a  rheumatic  in- 
volvement of  the  muscle-sheaths  or  the  tendons.  The  jintient 
sometimes  mistakes  for  paralytic  weakness'  the  restraint  of 
motion  by  pain.  The  pain  is  also  in  some  degree  spontaneous 
and  influenced  by  meteorologic  conditions.  Affecting  the  mus- 
cles of  the  lumbar  region,  the  condition  is  termed  lumhago. 
Affecting  the  muscles  of  the  neck  it  may  give  rise  to  torticollis 
or  wry-neck. 

How  are  subacute  rheumatism  and  neuralgia  to  be  differ- 
entiated ? 
Both  subacute  rheumatism  and  neuralgia  occur  in  paroxysms, 
superinduced  by  suitable  meteorologic  conditions.  Eheumatism 
is  more  common  in  men  ;  neuralgia  in  women.  The  pain 
of  the  former  is  rather  dull  and  diffused  ;  that  of  the  latter 
sharp  and  confined  to  the  distribution  of  an  affected  nerve,  in 
the  course  of  which  may  be  found  several  tender  points.  Rheu- 
matic pain  more  commonly  than  neuralgic  pain  is  aggravated 
by  movement. 

How  are  subacute  rheumatism  and  trichiniasis  to  be  differen- 
tiated? 

In  trichiniasis,  in  addition  to  symptoms  simulating  those  of 
subacute  rheumatism,  there  are  evidences  of  a  cachexia,  wasting, 
debility  and  symptoms  of  gastro-intestinal  derangement,  with 
a  history  of  the  ingestion  of  diseased  meat.  At  an  advanced 
stage  of  the  disease,  it  may  be  possible  to  detect  the  nodules  to 
which  the  encapsulated  parasites  give  rise.  Leukocytosis  with 
eosinophilia  is  characteristic  of  trichiniasis. 

Myalgia. 

What  is  myalgia  ? 

As  a  result  of  muscular  strain,  or  of  traumatism,  groups  of 
muscles  become  painful  to  touch  and  on  movement,  in  associa- 
tion with  some  degree  of  cutaneous  hyperesthesia. 


CHRONIC    RHEUSIATISM ACLTK    CJ  U  L'T  .  99 

Chronic  Rheumatism. 

What  are  the  symptoms  of  chronic  rheumatism  ? 

As  a  result  of  an  attack  or  of  repeated  attacks  of  acute 
rheumatism,  numerous  joints  in  different  parts  of  the  body 
remain  enlarged,  stiff  and  painful.  Sometimes  the  condition 
is  insidious,  progressive  and  chronic  from  the  outset.  How- 
ever produced,  the  functions  of  the  various  joints  are  impaired  ; 
attacks  of  pain  occur  and  are  apparently  influenced  by  meteor- 
ologic  conditions.  Wasting  of  the  muscular  structures  adja- 
cent to  the  diseased  joints  takes  place. 

Chronic  rheumatism  may  affect  both  joints  and  muscles,  or  the 
muscle  sheaths  or  tendons  only  (muscular  rheumatism) ,  or  it  may 
attack  the  nerve-sheaths  (rheumatic  neuralgia).  The  principal 
sj'mptoms  of  muscular  and  of  nerve-rheumatism  are  pain,  spon- 
taneous and  on  motion,  with  accompanying  tenderness,  usually 
localized. 

How  are  the  enlarged  joints  of  chronic  rheumatism  to  be  dis- 
tinguished from  those  of  chronic  spinal  disease  ? 

Trophic  changes  in  the  large  joints — enlargement,  effusion, 
subluxation,  arthropathies — take  place  in  the  course  of  some 
chronic  spinal  affections,  notably  posterior  spinal  sclerosis.  As 
a  rule,  but  one  or  a  few  joints  are  involved.  In  chronic  rheu- 
matism, many  joints  are  involved.  In  case  of  disease  of  the 
spinal  cord  ordinary  scrutiny  should  detect  the  existence  of 
symptoms  indicative  of  such  a  condition. 

Acute  Gout, 

What  are  the  symptoms  of  acute  gout  ? 

Acute  gout  is  a  recurrent  paroxj^smal  affection  thought  to  be 
dependent  upon  the  presence  of  an  excess  of  uric  acid  in  the 
blood.  It  occurs  chiefly  in  those  of  a  sedentary  or  inactive  mode 
of  life,  who  indulge  excessively  in  the  luxuries  of  the  table,  more 
especially  in  meats,  sweets,  sweet  wines  and  malt  liquors.  Those 
that  have  been  active  in  out-door  sports  and  afterwards,  while 
diminishing  their  exercise,  maintain  the  heavy  diet  formerly 


100  ESSENTIALS    OF    DIAGNOSIS. 

appropriate,  are  extremely  liable  to  gout.  The  tendency  to  gout 
is  distinctly  hereditary,  and  in  some  cases  of  marked  gouty  di- 
athesis the  attacks  may  occur  despite  personal  abstemiousness. 

The  paroxysm  may  be  brought  on  by  an  unusual  excess,  by  a 
fit  of  anger,  by  worry  or  anxiety  or  by  exhaustion.  Its  advent 
is  sometimes  unannounced  ;  at  other  times,  it  is  preceded  by 
symptoms  of  indigestion,  by  mental  irritability  or  depression. 
The  attack  usually  sets  in  suddenly  at  night,  the  patient  being 
awakened  by  intense  pain  most  commonly  referred  to  the  meta- 
tarso-phalangeal  joint  of  the  great  toe.  There  is  fever  in  pro- 
portion to  the  intensity  of  the  local  affection.  The  pain  mode- 
rates somewhat  towards  morning,  when  the  patient  falls  into  a 
gentle  perspiration  and  is  again  able  to  sleep.  Towards  night 
the  pain  returns.  The  joint  is  now  noticed  to  be  tender,  red, 
swollen  and  edematous ;  finally  desquamation  takes  place. 
Other  joints  are  successively  involved,  the  morbid  process  show- 
ing an  affinity  for  the  smaller  articulations.  The  attack  gradu- 
ally subsides,  leaving  the  affected  joints  a  little  stiffened  and 
swollen.  At  the  height  of  the  attack  the  proportion  of  uric 
acid  in  the  blood  is  increased,  while  that  excreted  in  the  urine 
is  diminished.  When  the  paroxysm  is  over  the  quantity  of  uric 
acid  in  the  urine  is  increased.  In  an  attack  of  acute  gout,  the 
joint-symptoms  may  suddenly  subside,  and  gastric,  cardiac  or 
even  cerebro-spinal  symptoms  be  substituted. 

Sometimes  the  attack  is  manifested  from  the  first  by  visceral 
rather  than  by  articular  crises.  Visceral  crises  are  more  likely 
to  occur  late  in  the  history  of  the  case  than  early  in  its  course, 
and  they  sometimes  prove  fatal. 

How  are  acute  rheumatism  and  acute  gout  to  be  differentiated  ? 

Gout  is  an  hereditary  aftection,  occurring  in  paroxysms,  in 
which  the  first  metatarso-phalangeal  articulation  and  other  small 
joints  are  involved.  In  acute  rheumatism,  a  history  of  heredity 
is  frequently  wanting  ;  the  large  joints  are  especially  involved. 
The  duration  of  an  attack  of  rheumatism  is  many  weeks  ;  an 
attack  of  gout  subsides  in  the  course  of  a  week  or  two.  The 
uratic  deposits  of  gout  are  wanting  in  rheumatism.  The 
sweats  of  rheumatism  are  absent  from  gout.  Cardiac  complica- 
tions are  common  in  acute  rheumatism  ;  gout  never  occasions 


CHRONIC    GOUT  —  LITHEMIA.  101 

endocarditis,  but   chronic   interstitial    nephritis  is  a  common 
sequel. 

Chronic  Gout. 

What  is  chronic  gout  ? 

In  those  that  have  had  a  number  of  paroxysms  of  acute  gout, 
or  sometimes  chronicah}'  from  the  first,  deposits  of  urates  take 
place  around  the  diseased  joints,  in  the  articular  cartilages  and 
elsewhere,  as  in  the  lobe  of  the  ear,  in  the  kidneys  and  in  the 
spleen.  As  a  result  there  is  painful  thickening  of  the  affected 
articulations,  which  are  stiff  and  finally  become  deformed. 
Sometimes  distinct  "  chalk-stones"  may  be  felt,  and  in  extreme 
cases  these  may  cause  ulceration  and  appear  externally.  Gout 
is  a  potent  cause  of  arterio-capillary  fibrosis.  An  excess  of 
fibrous  tissue  develops  in  the  viscera  and  in  the  walls  of  the  blood- 
vessels, with  secondary  contraction.  Chronic  interstitial  ne- 
phritis is  a  common  sequel. 

Lead-poisoning  may  give  rise  to  lesions   exactly  resembling 
those  of  chronic  or  of  subacute  gout. 


Lithemia. 

What  are  the  clinical  features  of  lithemia  ? 

Lithemia  is  modified  gout — a  manifestation  of  the  uric-acid 
diathesis.  It  is  caused  by  defective  oxidation  within  the  body 
and  is  dependent  upon  imperfect  tissue-metabolism. 

Lithemia  manifests  itself  by  varied  symptoms,  among  which 
are  sallowness  or  abnormal  redness  of  complexion,  impaired  or 
perverted  appetite,  a  metallic  taste,  deranged  digestion,  consti- 
pation, at  times  alternating  with  diarrhea,  in  some  cases  with  the 
passage  of  mucous  casts  of  the  bowel,  headache,  vertigo,  irrit- 
ability of  temper,  a  tendency  to  neurasthenia  or  melancholia, 
abnormal  drowsiness  or  sleeplessness,  palpitation  of  the  heart, 
precordial  distress,  irritative  cough,  disturbance  of  vision,  noises 
in  the  ears,  anomalous  cutaneous  eruptions,  transient  localized 
edema,  and  cramps  in  the  calves  of  the  legs.  Micturition  may 
be  frequent  and  burning,  the  urine  usually  being  diminished  in 


102  ESSENTIALS    OF    DIAGNOSIS. 

quantity,  of  high  specific  gravity,  and  containing  an  excess  of 
uric  acid  and  urates;  phosphates  and  calcium  oxalate  are  like- 
wise frequently  in  excess;  albumin  and  tube-casts  are  some- 
times found,  and  in  cases  attended  with  paroxysmal  flushing 
red  blood-corpuscles  likewise.  Chronic  catarrhal  hepatitis  and 
functional  inactivity  of  the  liver  are  frequently — perhaps  caus- 
ally— associated  with  lithemia.  Fibrous  degeneration  of  the 
kidneys  and  of  the  walls  of  the  smaller  arteries,  with  cardiac 
hypertrophy,  may  be  an  ultimate  sequel. 

For  what  affections  may  lithemia  be  mistaken? 

Unless  in  a  given  case  one  bears  in  mind  the  possibility  of  the 
existence  of  lithemia,  and  is  on  the  alert  for  its  detection,  the 
condition  may  be  mistaken  for  almost  any  functional  disorder, 
or  even  for  serious  organic  disease  of  the  heart,  brain,  stomach, 
intestine,  or  other  organ. 

The  discrimination  depends  partly  upon  the  exclusion  of  vis- 
ceral lesions,  and  partly  upon  the  results  of  urinalysis  :  the 
finding  of  an  excess  of  urates  or  free  uric  acid  pointing  to  the 
existence  of  lithemia.  An  hereditary  tendency  to  gout  or  rheu- 
matism, or  the  existence  of  gout,  rheumatism,  or  diabetes  in 
other  members  of  the  patient's  family,  or  the  fact  that  the 
patient's  habits  of  life  are  such  as  are  likely  to  lead  to  the  de- 
velopment of  gout,  should  direct  attention  to  the  probability  of 
the  existence  of  lithemia. 

It  must  not  be  forgotten  that  fibroid  changes  in  the  blood- 
vessels and  kidneys  are  frequent  concomitants  of  the  uric-acid 
diathesis. 

Rheumatoid  Arthritis — Arthritis  Deformans. 

What  are  the  clinical  features  of  rheumatoid  arthritis  ? 

Hhcwniatoid  arthritis,  arthritis  deformans,  often  incorrectly 
called  rheumatic  gout,  is  a  morbid  condition  in  which  destructive 
changes  take  place  in  one  or  more  joints  of  the  body,  resulting 
in  thickening,  impairment  of  mobility,  deformity  and  pain.  The 
articular  cartilages  undergo  softening  and  absorption ;  the  ends 
of  the  bones  become  enlarged  and  sclerotic,  while  the  apposed 


KUEUMATOID    ARTIIRITIS.  103 

surfaces  become  smooth  from  mutual  pressure  ;  the  suljjacent 
bone,  however,  becomes  rarefied  and  brittle  ;  lime-salts  are  de- 
posited in  the  remains  of  the  articular  cartilages.  A  peculiar 
crepitus  due  to  the  apposition  of  roughened  surfaces  can  often 
be  elicited  on  manipulation  of  the  afiected  joint.  At  a  later 
stage,  eburnation  takes  place,  and  the  apposed  bony  surfaces 
slide  over  one  another  Avith  abnormal  facility. 

The  disease  manifests  a  tendency  to  symmetrical  involvement. 
When  the  hands  are  involved,  a  peculiar  deformity  results — the 
fingers  being  deflected  towards  the  ulnar  side.  Occasionall}?-, 
hard  fibrous  nodules  are  found  in  the  muscles  at  a  short  distance 
from  the  affected  joints. 

In  some  cases  nodes  form  at  the  sides  of  the  terminal  pha- 
langes.    Less  commonly  a  single  joint  is  affected. 

The  onset  of  the  disease  is  usually  insidious  ;  occasionally  it  is 
acute  and  attended  with  febrile  symptoms,  with  pain,  with 
swelling  and  with  redness  of  the  affected  joints. 

Arthritis  deformans  occurs  in  those  exposed  to  unfavorable 
hygienic  influences,  in  the  weak  and  ill-fed,  in  those  exhausted 
by  frequent  childbearing,  b}^  prolonged  lact^ation,  by  grief  or  by 
anxiety. 

The  disease  is  not  directly  fatal.  It  occasions  no  cardiac  com- 
plication. When  the  larger  joints  (especially  the  hip,  knees  and 
elbowsj  are  involved  there  often  results  decided  7riuscular  atrryphy. 

How  are  chronic  rheumatism  and  rheumatoid  arthritis  to  be 
differentiated  ? 

In  rheumatism,  the  larger  joints  of  the  body  are  especially  in- 
volved ;  rheumatoid  arthritis  involves  the  smaller  joints  as  well. 
The  deformity  of  rheumatism  is  essentially  dependent  upon  a 
hyperplasia  of  the  fibrous  structures  that  enter  into  the  forma- 
tion of  the  articulation  ;  the  joiiit-lesions  of  rheumatoid  arthritis 
are  partly  destructive  in  character  and  occasion  peculiar  de- 
formities of  the  hands  and  feet,  while  irregular  exostoses  form 
on  the  articular  extremities  of  the  bones.  The  tendency  to 
symmetrical  invasion  is  more  conspicuous  in  rheumatoid  arthritis 
than  in  chronic  rheumatism.  The  latter  is  usually  a  disease  of 
advanced  life  ;  the  former  may  appear  in  early  adult  life. 


104  ESSENTIALS    OF    DIAGNOSIS. 

How  are  gout  and  rheumatoid  arthritis  to  be  differentiated  ? 

Rheumatoid  ai'tlu'itis  lacks  the  paroxysmal  chararter  of  gout. 
Unlike  gout,  it  is  observed  in  the  underfed  rather  than  in  the 
overfed.  In  rheumatoid  arthritis  the  deposits  of  uric  acid  and 
of  urates  in  various  structures,  characteristic  of  gout,  are  want- 
ing. Gout  never  presents  the  peculiar  deformities  of  the  hands 
and  feet  seen  in  rheumatoid  arthritis.  The  latter  does  not  lead 
to  the  fibroid  condition  of  the  kidneys,  heart  and  vessels  to  which 
gout  2:ives  rise. 

THE  BLOOD. 

What  are  the  methods  of  studying  the  constitution  of  the  blood  ? 

For  purposes  of  diagnosis  especially,  the  blood  is  frequently 
examined  as  to  its  corpuscular  richness^  as  to  the  proportion  of 
hemoglobin  it  contains,  and  as  to  tlie  presence  of  abnormal 
bodies. 

The  corpuscular  richness  of  the  blood  is  determined  by  means  of 
an  instrument  called  a  hemocytometer  or  blood-cell  counter,  which 
consists  of  a  shallow  cell  of  known  capacity,  mounted  on  a  glass 
slide,  in  microscopic  divisions  of  which  the  numbers  of  red  and 
white  blood-corpuscles  contained  in  a  centesimal  dilution  of 
blood  are  respectively  comited.  For  enumerating  the  white 
cells  alone  a  decimal  dilution  is  to  be  preferred.  The  number 
of  cells  can  also  be  determined  by  the  ^use  of  the  hematokrit,  a 
centrifugal  apparatus  provided  with  graduated  capillary  tubes 
of  known  calibration.  In  healthy  men  the  blood  contains  about 
five  million  red  corpuscles  to  the  cubic  millimeter;  in  women, 
about  four  and  a  half  millions.  The  number  of  white  cells  is 
held  not  to  permanently  exceed  under  normal  conditions, 
10,000  per  cubic  millimeter.  The  normal  ratio  of  white  cells  to 
red  cells  varies  between  1  :  400  and  1 :  800. 

Differential  studies  of  the  leukocytes  are  made  with  the  aid 
of  selective  stains.  The  blood,  spread  in  a  thin  layer  on  a 
cover-slip  or  slide,  is  fixed  by  heat  or  otherwise  and  exposed  to 
the  action  of  eosin  and  methylene-blue  or  hematoxylin,  etc. 
Several  varieties  of  leukocytes  are  distinguished,  in  accordance 
with  their  morphology  and  their  staining  affinities:  (1)  small 


TUE    BLOOJD.  105 

mononuclear,  or  lymphocytes,  from  15  to  25%  ;  (2)  lare^e  mono- 
nuclear, from  3  to  6%  ;  (3)  polymorphonuclear  or  neutrophiles, 
from  65  to  75%  ;  or  (a)  acidophile  or  eosinophile,  from  1  to 
7%  ;  (b)  basophile,  from  20  to  25%  ;  (c)  neutrophile,  from  65 
to  75%. 

The  proportion  of  hemoglobin  in  the  blood  is  determined  by 
comparing  the  color  of  the  diluted  blood  with  a  standard,  called 
a  hemoglobinometer  or  hemometer,  the  result  being  expressed  in 
percentages.  ' 

The  percentage  of  hemoglobin  is  sometimes  spoken  of  as  ab- 
solute ov  total ;  sometimes  as  reZatire.  By  the  term  absolute  per- 
centage is  m^ant  the  comparative  richness  in  hemoglobin  of  the 
whole  volume  of  blood,  as  shown  by  the  direct  reading  of  the 
hemoglobinometer  scale.  By  relative  percentage  is  meant  the 
relation  or  ratio  of  the  absolute  hemoglobin  percentage  to  the 
percentage  of  red  corpuscles.  Thus,  if  in  a  given  case,  the 
number  of  red  corpuscles  to  the  cubic  millimeter  is  estimated  at 
3,000,000,  or  60%  (5,000,000  being  taken  as  the  standard  or  100 
per  cent.),  and  the  hemiglobinometer  reading  is  54  per  cent.,  the 
latter  figure  (54%)  would  represent  the  absolute  hemoglobin  per- 
centage, while  the  relative  hemoglobin  percentage  would  be  f  § 
or  90  per  cent. 

Deficiency  of  blood  is  known  as  anemia  or  oligemia  ;  deficiency 
of  corpuscles,  as  oligocythemia;  deficiency  of  hemoglobin,  as  oligo- 
chromemia;  deficiency  in  solid  constituents  of  the  plasma, 
especially  albumin,  as  hydremia.  Excess  of  white  corpuscles 
may  appropriately  be  designated  hyperleukocytosis ;  deficiency 
of  white  corpuscles,  hypoleukocytosis.  The  morbid  condition,  of 
which  persistent  excess  of  white  corpuscles  is  often  the  most 
conspicuous  and  is  perhaps  the  essential  feature,  is  known  as 
leukemia  or  leukocythemia.  The  normal  diameter  of  the  red 
blood-corpuscle  is  7//.  Smaller  red  corpuscles  are  called  micro- 
cytes;  larger,  megalocytes.  Irregularly-shaped  red  corpuscles  are 
called  poikilocytes. 

The  blood  sometimes  contains  parasites,  such  as  the  hema- 
tozoa  of  malaria,  the  spirilla  of  relapsing  fever,  the  bacilli  Of 
anthrax,  the  embryos  of  filaria  sanguinis  hominis,  etc. 


106  ESSENTIALS    OF    DIAGNOSIS. 

Anemia. 

What  are  the  symptoms  of  anemia  ? 

Simple  anemia  may  be  a  result  of  hemorrhage,  of  long-con- 
tinued discharges,  of  syphilis,  malaria,  fevers  and  wasting  dis- 
eases, of  mal-assimilation,  of  impaired  nutrition,  of  the  presence 
of  parasites  or  of  poisons  in  the  system. 

The  blood  is  deficient  in  quantity  and  in  quality.  The  actual 
volume  of  the  circulating  Huid,  as  well  as  its  corpuscular  rich- 
ness, is  diminished.  The  number  of  red  cells  and  the  number  of 
ichite  cells  are  less  than  normal ;  so  is  the  absolute  quantity  of 
hemoglohin,  while  the  relative  proportion  per  corpuscle  may  be 
scarcely  altered.  Some  of  the  red  cells  are  ill-shaped  and 
diminutive,  and  some  nucleated. 

Anemia  long  continued  gives  rise  to  fatty  degeneration  of 
various  structures,  notably  of  the  walls  of  the  bloodvessels,  of 
the  heart  and  of  other  viscera. 

The  countenance  and  visible  mucous  membranes  are  usually 
pale  ;  though  in  exceptional  instances  of  great  vascularity  of  the 
face  the  complexion  may  be  rosy.  The  eyeball  has  a  bluish  tint. 
There  are  shortness  of  breath,  an  undue  readiness  of  fatigue, 
and  a  disinclination  to  mental  or  physical  effort.  The  patient 
complains  of  neuralgia,  of  headache,  of  vertigo  and  of  sleep- 
lessness. The  appetite  and  digestion  are  impaired  ;  constipation 
is  the  rule.  The  urine  is  pale  and  may  be  of  low  specific  gravity, 
from  diminution  in  urea.  Emaciation  is  not  always  evident. 
The  action  of  the  heart  is  enfeebled.  Palpitation  is  common. 
The  pulse  is  soft,  compressible,  and  usually  small.  A  soft,  blow- 
ing murmur  is  often  to  be  heard  at  the  base  of  the  heart  and 
in  the  vessels  of  the  neck  ;  in  the  arteries  less  constantly  than  in 
the  veins  (venous  hum,  ^^hruii  de  diahW^).  Edema  ultimately 
develops  and  hemorrhages  from  various  surfaces  may  take  place. 

When  anemia  is  associated  with  enlargement  of  the  spleen  it 
is  termed  splenic  anemia.  By  some  authorities  splenic  anemia 
is  considered  to  be  a  variety  of  pseudo-leukemia.  In  the  yellow, 
waxen  countenance  of  its  subjects,  in  its  clinical  course,  which 
is  sometimes  remittent  or  intermittent,  in  its  intensity  and  its 
fatality,  the  disease  closely  resembles  pernicious  anemia.     Un- 


CHLOROSIS  —  PERNICIOUS    ANEMIA.  107 

like  the  latter  affection,  splenic  anemia  presents  a  definite  visce- 
ral lesion,  a  relative  increase  of  white  Cf3lls,  and  a  diminution  in 
the  relative  percentage  of  hemoglobin. 

Chlorosis. 

What  are  the  symptoms  of  chlorosis? 

Chlorosis  or  green-sickness  is  a  depraved  condition  of  the 
blood,  seen  especially  at  about  the  time  of  puberty  in  young 
w^omen,  with  derangement  of  menstruation.  In  addition  to 
the  symptoms  of  simple  anemia^  the  complexion  and  the  con- 
junctivae present  a  yellowish-green  hue.  The  number  of  red 
corpuscles  is  not  diminished  in  the  same  degree  as  is  the  per- 
centage of  hemoglohin,  while  the  number  of  leukocytes  is  not 
appreciably  altered. 

Pernicious  Anemia. 

What  are  the  symptoms  of  pernicious  or  idiopathic  anemia  ? 

There  is  a  form  of  anemia  in  which  the  impoverishment  of 
the  blood  is  marked,  and  which  pursues  a  progressive  and  usually 
fatal  course.  It  is  more  common  in  men  than  in  women.  No 
constant  visceral  lesion  has  been  found  associated  with  the 
disease.  In  some  instances,  there  has  been  atrophy  of  the  gas- 
tric glands  ;  in  others,  disease  of  the  medulla  of  the  hones  ;  in 
others,  increase  of  iron-containing  pigment  in  the  liver  ;  in  still 
others,  no  lesion  except  that  of  the  blood  has  been  detected. 
The  disease  sometimes  appears  in  connection  with  pregnanc3\ 

The  symptoms  are  those  of  intense  anemia,  with  irregular  out- 
breaks of  febrile  temperature.  The  complexion  is  pallid  and 
often  assumes  a  strikingly  yellowish  (lemon)  hue.  The  lips  and 
palpebral  conjunctivae  may  be  white.  The  bones,  especially  the 
sternum,  exhibit  tenderness  on  pressure.  The  pAilse  is  usually 
rapid.  The  urine  may  be  notably  dark-colored,  and  contains  an 
excess  of  nitrogenous  matters. 

Sometimes  deceptive  remissions  in  the  symptoms  occur.  The 
layer  of  subcutaneous  fat  is  often  well-preserved.  Hemorrhages 
take  place  from  the  mucous  surfaces,  beneath  the  skin,  into  the 


lOS  ESSENTIALS   OF   DIAGNOSIS. 

retina  and  elsewhere,  as  a  result  of  fatty  degeneration  of  the 
coats  of  the  arteries.  The  heart  is  also  likely  to  undergo  fatty 
degeneration. 

The  volume  of  blood  is  small ;  the  number  of  red  corpuscles 
is  considerably  diminished  (less  than  2,000,000  per  c.  mm.),  as 
is  necessarily  the  absolute  quantity  of  liemoglohin^  of  which, 
however,  the  relative  proportion  per  corpuscle  is  increased. 
The  red  corpuscles  are  poorly  developed  and  ill-shaped ;  some 
are  nucleated.  Megalocytes  preponderate ;  microcytes  and 
poikilocytes  are  likewise  found.  In  some  cases  minute,  highly- 
colored  globules  resembling  "  small  red-tinged,  fiit  globules  "  are 
seen.  The  number  of  white  corpuscles  may  remain  unaltered ; 
in  some  cases,  it  has  been  increased;  in  others,  diminished. 

What  special  precautions  must  be  taken  in  arriving  at  a 
diagnosis  of  the  various  forms  of  anemia  ? 
When  a  condition  of  anemia  is  discovered,  a  searching  in- 
quiry into  the  history  and  symptoms  and  a  careful  physical 
examination  must  be  made,  to  determine  whether  or  not  there 
be  a  coexistent  morbid  condition,  such  as  carcinoma,  tuber- 
culosis, hemorrhoids  or  other  source  of  hemorrhage,  nephritis, 
malarial  infection,  intestinal  parasites,  defective  or  insufficient 
nutrition,  mal-assimilation,  arsenical,  plumbic,  mercurial  or 
other  form  of  poisoning,  and  conditions  that  occasion  jaundice. 

Hyperleukocytosis  (Leukocytosis). 

What  is  leukocytosis  ? 

Leukocytosis  is  a  condition  of  the  blood  in  which,  without 
alteration  in  the  number  of  red  corpuscles,  without  enlargement 
of  the  spleen,  of  the  liver  or  of  the  lymphatic  glands,  the  num- 
ber of  white  corpuscles  undergoes  an  intermittent  or  transitory 
increase,  involving  especially  the  polymorphonuclear  cells.  It 
may  he  physiologic,  as  when  it  occurs  after  meals,  during  preg- 
nancy or  in  the  newborn ;  or  pathologic,  as  when  it  occurs  in 
association  with  suppuration,  the  various  diseases  of  the  blood 
and  lymphatic  glands,  as  chlorosis,  pernicious  anemia,  leuke- 
mia; inflammatory,  suppurative  and  exudative  conditions  (in- 
cluding infections),  as  pleurisy,  pericarditis,  meningitis,  nephri- 


LEUKEMIA.  109 

tis,  acute  .articular  rhouinatisni,  diphtlicria,  erj'sipclas,  scarlet 
fever,  variola,  cholera,  tetanus,  trichiniasis;  malignant  disease, 
carcinoma  and  sarcoma;  after  the  use  of  certain  medicinal 
agents,  jxs  pilocarpin,  antipyrin,  nuclein,  camphor,  ethereal 
oils,  bitters,  etc. ;  or  it  may  be  a  transitional  stage  of  leukemia 
or  pseudo-leukemia. 

Leukemia. 

What  is  leukemia  or  leukocythemia  ? 

Leukemid  is  a  morbid  condition  in  which,  in  association  with 
enlargement  of  the  spleen,  of  the  liver,  of  lymphatic  glands,  or 
•with  alterations  in  the  medulla  of  bones,  the  blood  contains  a 
permanent  excess  of  leukocytes  and  is  deficient  in  reel  cells 
(Fig.  18). 

Fig.  18. 


Appearance  of  the  blood  iu  leukemia.     (Funke.) 

Three  varieties  of  leukemia  are  recognized  :  lienal,  lymphatic 
and  medullary^  as  the  spleen  and  liver,  the  lymphatic  system, 
and  the  medulla  of  bones,  respectivel}',  are  involved. 

Early  in  the  course  of  the  disease,  the  spleen  becomes  con- 
spicuously enlarged  ;  sometimes  friction-fremitus  may  be  de- 
tected on  palpation,  and  a  blowing  murmur  on  auscultation ; 


110  ESSENTIALS    OP    DIAGNOSIS. 

ascites  maj^  develop.  In  the  further  course  of  the  disease,  the 
liver  and  the  lymphatic  glands  may  also  become  enlarged  ;  ihe 
bones  may  be  painful  and  tender  ;  changes  in  the  kidneys  and  in 
the  intestinal  glands  are  sometimes  noted. 

The  number  of  luhite  corpuscles  in  the  blood  is  increased 
beyond  10,000  to  the  cubic  millimeter,  sometimes  in  extraordi- 
nary degree.  The  number  of  red  cells  and  the  quantity  of  hemo- 
globin are  diminished.  Through  increase  in  the  number  of  the 
white,  and  diminution  in  that  of  the  red,  there  ensues  a  great 
change  in  the  ratio  of  white  cells  to  red  cells.  The  ratio  is,  as  a 
rule,  not  less  than  1  :  50,  and  may  reach  or  exceed  1  : 1.  Masses  of 
leukocytes  may  occasion  infarcts  in  the  spleen  or  lungs.  It  is 
said  that  in  lienal  leukemia  large  leukocytes  predominate  ;  in 
lymphatic  leukemia,  small  leukocytes  ;  and  in  myelogenous  leu- 
kemia, large  leukocytes,  having  large  nuclei,  together  with 
transition-types  and  many  eosinophile  cells. 

The  depravity  of  the  blood  occasions  dyspnea  and  edema  ; 
conjoined  with  the  secondary  changes  in  the  bloodvessels,  it 
predisposes  to  extravasation  of  the  blood.  There  are  thus 
breathlessness  on  exertion,  epistaxis  and  other  hemorrhages 
from  mucous  surfaces  and  into  the  retina  and  subcutaneous 
connective  tissue.  Diarrhea  is  common.  The  urine  contains 
an  excess  of  uric  acid.  Rarely,  disturbances  of  vision  occur- 
as  a  result  of  hemorrhage,  of  leukemic  deposit,  or  of  leukemic 
retinitis.  From  time  to  time  febrile  periods,  lasting  from  a  few 
days  to  a  week,  in  which  the  temperature  may  rise  to  102°  F., 
are  observed.  Remissions  in  all  of  the  symptoms  sometimes 
take  place  during  the  progress  of  the  case. 

Leukemia  is  most  common  between  the  ages  of  twenty  and 
fifty  ;  it  is  more  common  in  men  than  in  women.  It  is  usually 
insidious  in  onset,  the  early  clinical  phenomena  being  those  of 
anemia^  in  general.  Sometimes  the  disease  pursues  a  rapidly 
fatal,  course.  Epistaxis  is  often  the  first  significant  symptom. 
The  etiology  of  leukemia  is  obscure.  In  some  cases  there  has 
been  a  history  of  antecedent  malarial  infection ;  in  others,  of 
traumatism  of  the  spleen ;  in  others,  of  traumatism  of  bones. 
Privation  and  exposure  are  cited  among  predisposing  and  ex- 
citing causes. 


PSEUDO-LEUKEMIA.  Ill 

Pseudo-leukemia. 

What  is  pseudo-leukemia  ? 

Fscudo-lcukcmla,  IIodykin''s  disease,  lymphatic  anemia,  malig- 
nant lymphoma  or  hjmphadenama^  is  an  affection  characterized  by 
hyperplasia  of  adenoid  tissues,  and  especially  by  enlargement  of 
the  lymphatic  orjands  in  various  parts  of  the  body,  and  by 
changes  in  the  blood.  Anemia  prevails,  the  number  of  red.  cor- 
puscles and  the  relative  proportion  of  hemoglohin  being  dimin- 
ished, the  number  of  white  corpuscles  remaining  unchanged  or 
not  uncommonly  being  slightly  increased.  An  apparent  excess 
of  white  cells,  due  to  decrease  in  the  number  of  red  cells,  with 
consequent  moderate  elevation  of  the  ratio,  must  not  be  mis- 
taken for  an  actual  increase  in  the  number  of  leukocytes.  The 
superficial  glands,  especially  those  of  the  neck  and  axilla,  are 
usually  chiefly  involved.  Sometimes  the  glandular  enlargement 
is  first  noticed  in  the  groin.  The  spleen,  liver  and  other  viscera 
may  also  be  enlarged.  In  addition  to  the  symptoms  of  anemia 
and  malnutrition,  pressure-phenomena  are  observed.  Enlarge- 
ment of  the  tonsils,  of  the  lingual,  postnasal,  cervical,  peri- 
tracheal and  peri-bronchial  glands  gives  rise  to  cough,  dyspnea 
and  dysphagia.  The  cerebral  circulation  may  be  impeded  from 
pressure  upon  the  vessels  of  the  neck.  Pressure  upon  nerves 
may  cause  paralysis,  pain  or  edema.  Jaundice  and  ascites  are 
sometimes  observed.  There  are,  in  addition,  a  tendency  to 
effusions,  hemorrhages  and  petechise,  and  from  time  to  time 
febrile  periods. 

How  are  leukemia  and  pseudo-leukemia  to  be  differentiated  ? 

It  is  possible  that  leukemia  and  pseudo-leukemia  represent 
stages  of  a  single  condition.  Individual  cases  present  symp- 
toms of  both  aflections.  The  difterentiation  of  well-marked 
cases,  however,  is  not  difficult. 

In  leukemia,  the  spleen  enlarges  early  ;  the  lymph-glands 
are  not  necessarily  involved  ;  when  they  are,  however,  it  is  late 
in  the  disease.  In  pseudo-leukemia,  the  lymph-glands  are 
primarily  enlarged  ;  the  spleen  and  liver  ma}-  escape  entirely  ; 
should  the}'  become  involved,  it  is  late  in  the  disease.  In  leuke- 
mia,   the   number  of  white   blood-cells    is   always  increased — 


112  ESSENTIALS    OF  DIAGNOSIS. 

often  in  decided  degree.  The  alteration  of  relation  of  white 
cells  to  red  cells  in  pseudo-leukemia  is  due  to  decrease  in  the 
number  of  the  red  cells  ;  actual  excess  of  white  cells  constitutes 
no  essential  part  of  the  disease  ;  though  not  rarely  observed, 
it  never  reaches  the  high  figures  of  leukemia. 

How  are  tuberculosis  of  the  lymph-glands  ("scrofula")  and 
pseudo-leukemia  to  be  differentiated  ? 

The  lymphatic  glands  over  a  wide  distribution  may  become 
tuberculous.  Such  a  condition  will  also  be  associated  with 
anemia — so  that  a  clinical  picture  will  be  presented  simulating 
that  of  pseudo-leukemia.  Microscopic  examination  of  a  portion 
of  one  of  the  growths  will  disclose  the  presence  of  tubercle- 
bacilli  in  the  one  instance  and  a  condition  of  simple  hyper- 
plasia in  the  other. 

In  pseudo-leukemia  the  enlarged  glands  are  not  inflamed, 
and  do  not  give  rise  to  inflammation  in  the  surrounding  con- 
nective tissue.  They  are  not  hot  or  tender  to  the  touch  ;  they 
are  not  adherent  to  the  skin,  and  are,  as  a  rule,  freely  movable 
upon  each  other.  Tuberculous  glands  are  usually  adherent  to 
the  skin,  and  to  each  other,  and  manifest  a  tendency  to  chronic 
inflammation,  with  caseation  and  suppuration.  There  are  usu- 
ally other  evidences  of  tuberculosis  present,  in  the  bones,  joints, 
or  elsewhere  ;  and  the  fades  is  often  significant.  Glandular 
tuberculosis  and  pseudo-leukemia  may,  however,  coexist ;  or 
inflammatory  changes  may  be  set  up  by  traumatism  in  the 
glands  of  pseudo-leukemia. 

Infantile  Fseudo-leukemic  Anemia. 

What  is  infantile  pseudo-leukemic  anemia  ? 

Jaksch  has  described  in  infants  a  form  of  anemia  in  the  last 
stage  of  which  there  are  a  deficiency  of  red  corpuscles,  a  defi- 
ciency of  hemoglohin ,  and  an  increased  uumher  of  ^vhite  corpuscles. 

The  condition  differs  from  leukemia  in  that  the  increase  of 
white  corpuscles  is  not  so  great,  that  eosinophile  leukocytes  are 
never  present,  that,  while  the  spleen  is  enlarged,  the  liver  is 
not,  and  that  the  prognosis  is  favorable. 


SCORBUTUS, 


113 


Table  showing  alterations  in  the  constitvtion  of  the  blood 

in  disease. 


Number 

of 
red  cells. 

Number 

of 

white  cells. 

Proportion  u 

f  hemoglobin. 

Total. 

Per  red  cell. 

Anemia 

Diminished. 

Normal  or 
diminished. 

Diminished. 

Normal  or 
diminished. 

Chlorosis 

Diminished. 

Normal  or 
diminished. 

Greatly 
diminished. 

Diminished. 

Pernicious  anemia 

Greatly 
diminished. 

Variable. 

Greatly 
diminished. 

Increased. 

Splenic  anemia     . 

Diminished. 

Increased. 

Diminished. 

Diminished. 

Pseudo-leukemia 

Diminished. 

Normal  or 
increased. 

Diminished. 

Normal  or 
diminished. 

Leukocytosis 

Normal. 

Increased. 

Normal. 

Normal. 

Leukemia 

Diminished. 

Greatly 
increased. 

Diminished. 

Normal  or 
diminished. 

Scorbutus. 

What  are  the  symptoms  of  scorbutus  ? 

Scorbutus  or  scurvy  is  a  disease  dependent  upon  dietetic  errors, 
especially  a  deficiency  in  certain  substances  usually  contained 
in  the  juices  of  fresh  vegetables  and  fruits.  It  was  formerly 
common  at  sea,  and  in  jails  and  poorhouses.  Outbreaks  still 
occasionally  occur.  Isolated  cases  sometimes  appear  under 
unexpected  circumstances,  as  in  adults  upon  restricted  diet 
and  in  children  on  artificial  food. 

The  disease  is  characterized  by  a  depraved  condition  of  the 
blood,  with  degeneration  of  the  walls  of  the  vessels  and  conse- 
quent hemorrhages.  The  gums  are  soft  and  spongy,  and  bleed 
on  slight  provocation  or  spontaneously.  The  breath  is  defiled 
by  the  fetor  of  the  decomposing  necrotic  tissue.  Hemorrhages 
take  place  from  other  mucous  surfaces,  while  inflammation  of 
serous  membranes,  with  hemorrhagic  effusions,  may  occur.  Ex- 
travasations of  blood  take  place  into  the  subcutaneous  tissues, 
especially  in  the  course  of  the  superficial  veins  of  the  dependent 
parts  of  the   body,  giving  a  mottled,  bluish  or  purplish  appear- 


114  ESSENTIALS    OF    DIAGNOSIS. 

a  nee  to  the  skin  in  more  or  less  extensive  areas.  Tlie  discolor- 
ation frequently  resembles  that  of  a  bruise,  and,  as  it  slowly 
fades,  assumes  a  greenish  tint.  It  is  often  quite  persistent. 
Extravasation  into  the  muscles  may  likewise  occur.  With 
this,  edema  is  often  associated.  Brawny  induration  of  the 
connective  tissue  in  various  parts  of  the  body  may  develop. 
Diliuse,  dull  pains  are  felt.  The  alin  is  dry  and  rough.  There 
is  mental  apathy,  with  a  sense  of  lassitude  and  an  undue 
readiness  of  fatigue.  Fungated  hemorrhagic  ulcers  form.  Ex- 
isting ulcers  assume  an  unhealthy,  spongy  appearance.  Frac- 
tured bones  fail  to  unite,  while  the  union  of  broken  bones  may 
l)e  dissolved.  The  complexion  is  sallow  ;  anemia  becomes  evi- 
dent, with  shortness  of  breath  and  rapidity  and  feebleness  of 
pulse.  In  children  pain  and  swelling  of  the  extremities,  with 
loss  of  mobility,  and  elevation  of  temperature  are  prominent 
symptoms.  In  some  epidemics,  dysentery  has  been  a  complica- 
tion. Sometimes  hemeralopia  or  night-blindness  has  been 
observed.  Without  proper  treatment  death  takes  place.  With 
proper  treatment  recovery  is  slow. 

Purpura. 

What  are  the  clinical  features  of  purpura  ? 

Purpura  is  a  manifestation  of  a  deteriorated  condition  of  the 
blood  and  vessels,  as  a  result  of  which  petechise  form,  and  hem- 
orrhages from  the  mucous  membranes  take  place.  Sometimes 
blood  is  extravasated  into  the  serous  cavities  ;  and  occasionally 
intracranial  hemorrhage  occurs.  The  disease  sometimes  devel- 
ops in  the  midst  of  apparent  health ;  at  other  times,  in  associ- 
ation with  infectious,  toxic,  cachectic  and  neurotic  states  and 
as  a  result  of  mechanical  conditions,  such  as  venous  stasis  and 
violent  muscular  strain.  Sometimes  articular  symptoms  are 
present.  Occasionally,  transient  febrile  periods  are  observed. 
Sometimes  the  disease  begins  acutely,  with  a  chill  followed  by 
pain  in  the  back  or  limbs,  but  without  fever.  The  purpuric 
spots  may  be  large  or  small,  of  limited  or  of  extensive  distribu- 
tion. Usually  they  appear  in  successive  crops.  At  first  red- 
dish, they  soon  become  of  a  deep  purple,  gradually  fading  to 


r  L  R  1>  U  R  A  .  115 

brown,  and  then  to  yellow,  as  they  disappear.  The  varieties  of 
purpura  commonly  recognized  are  purpura  simjjlex,  purpura 
hsemorrhagica  and  purpura  (or  peliosis)  rheumaiica.  The  names 
are  sufficiently  descriptive.  Henoch  has  described  a  recurring 
variety,  observed  especially  in  children  and  characterized  l)y  an 
erythematous  exanthem,  attacks  of  pain,  vomiting  and  diar- 
rhea, slight  articular  pain  or  swelling  and  hemorrhages  from 
mucous  membranes. 

How  are  scorbutus  and  purpura  to  be  differentiated  ? 

Scorbutus  occurs  among  those  that  are  massed  together  and 
are  insufficient!}^  supplied  with  fresh  vegetables  ;  purpura  may 
develop  amid  circumstances  apparently  the  most  favorable  and 
in  the  face  of  an  abundant  supply  of  fruits  and  vegetables. 
The  gums  may  bleed  in  purpura,  but  they  are  wanting  in  the 
sponginess  and  lividity  of  scorbutus.  The  breath  is  fetid  in 
scurvy,  not  necessarily  so  in  purpura.  The  petechiae  of  scor- 
butus usual!}'-  develop  about  the  hair-follicles  ;  those  of  purpura 
are  indifterent  in  distribution.  The  individual  discolored  patches 
are  more  extensive  in  scorbutus  than  in  purpura.  In  the  latter, 
large  blotches  can  usually  be  resolved  into  a  number  of  smaller 
spots  aggregated.  The  hue  in  the  two  cases  differs  to  the  ex- 
perienced eye.  Scorbutus  in  children  may  closely  simulate 
purpura. 

How  is  purpura  to  be  distinguished  from  measles  ? 

The  eruption  of  purpura  has  in  certain  instances  presented 
sufficient  superficial  resemblance  to  that  of  morbilli  to  occasion 
mistake— the  youth  of  the  patients  and  the  coincidence  of  febrile 
symptoms  increasing  the  difficulty.  The  course  of  the  eruption 
is,  however,  quite  different  in  the  two  affections.  The  distribu- 
tion of  the  purpuric  spots  is  not  so  general  as  is  that  of  the  erup- 
tion of  measles.  The  spots  of  purpura  often  appear  first  on  the 
legs,  while  in  measles  the  rash  begins  on  the  face  and  trunk. 
The  purpuric  spots  change  color  and  fade,  new  spots  appearing 
while  others  are  receding  ;  no  such  phenomenon  occurs  in 
measles.  Catarrhal  symptoms  do  not  occur  in  purpura  ;  hem- 
orrhages are  not  usual  in  measles.  The  characteristic  tempera- 
ture-curve of  measles  is  absent  from  the  course  of  purpura. 


116  ESSENTIALS    OF    DIAGNOSIS. 

Hemophilia. 

What  are  the  clinical  features  of  hemophilia  ? 

HeiuojjhiHa  is  a  morbid  condition  manifested  by  an  abnormal 
tendency  to  the  occurrence  of  hemorrhages,  spontaneously  or 
upon  slight  provocation.  Individuals  so  affected  are  called 
"bleeders."  The  disease  occurs  in  families:  it  is  much  the 
more  common  in  males,  but  is  mostly  transmitted  through 
females,  in  whom,  when  it  occurs,  its  manifestations  are  usually 
mild.  Slight  wounds,  a  scratch,  the  extraction  of  a  tooth,  may 
be  followed  by  alarming  or  even  fatal  hemorrhage.  Petechise 
form,  while  sometimes  large  extravasations  of  blood  take  place 
into  the  subcutaneous  textures  and  into  the  joints.  The  dis- 
ease usually  first  makes  its  appearance  early  in  life.  The 
diagnosis  depends  essentially  upon  the  history  of  hereditary 
transmission,  the  unusual  proneness  to  the  occurrence  of 
alarming  hemorrhage,  the  formation  of  petechise,  the  develop- 
ment of  subcutaneous  and  articular  extravasations  of  blood, 
and  the  appearance  of  the  first  symptoms  early  in  life. 

Addison's  Disease. 

What  are  the  clinical  features  of  Addison's  disease  ? 

Addison  observed  that  in  certain  cases,  in  which  after  death 
the  supra-renal  bodies  were  found  tuberculous,  there  had  existed 
during  life  a  peculiar  pigmentation  of  the  skin,  with  remark- 
able asthenia  and  nausea  and  vomiting.  The  discoloration  is 
usually  of  a  brownish  hue,  like  that  which  develops  in  one 
exposed  to  a  tropical  sun  ;  it  resembles  the  pigmentation  of  the 
dark-skinned  races.  It  occurs  in  plaques,  on  exposed  surfaces, 
at  parts  that  have  been  compressed  or  constricted,  in  the 
flexures  of  joints,  and  about  the  genitalia  and  the  nipples. 
The  mucous  membrane  of  the  mouth  and  tongue  may  be  pig- 
mented. Progressive  weakness  is  manifested  ;  and  prostration 
finally  develops.  The  subcutaneous  fat,  however,  may  be 
preserved.  The  hearVs  action  is  feeble  ;  the  pit?se  is  small  and 
compressible.  The  appetite  is  impaired  ;  nausea  and  vomiting 
are  common  ;    there  may  be  diarrhea  or  constipation.     Death 


RACHITIS.  117 

may  take  place  gradually,  from  exhaustion,  or  \\\{h  unexpected 
suddenness. 

Tuberculous  disease  of  the  supra-renal  bodies  has  been  found 
when  there  was  no  bronzing  of  the  skin.  In  such  cases  it  has 
been  thought  that  the  disease  had  not  progressed  sufiiciently 
to  have  occasioned  symptoms.  In  other  cases  the  skin  has  been 
pigmented,  but  no  changes  were  found  in  the  supra-renal  bodies. 
Pigmentation  of  the  skin  may,  however,  be  a  result  of  other 
conditions  than  supra-renal  disease.  By  some,  Addison's  dis- 
ease is  thought  to  depend  upon  loss  of  an  internal  secretion  of 
the  adrenals;  by  others  upon  changes  in  the  semilunar  ganglia 
and  branches  of  the  sympathetic  or  visceral  system  of  nerves. 

Bachitis. 

What  are  the  clinical  features  of  rachitis  ? 

Bachitis  is  a  disease  dependent  upon  defective  and  perverted 
development  of  the  osseous  structures  of  growing  children, 
probably  as  a  consequence  of  fault}'  nutrition.  There  is  doubt- 
less congenital  predisposition  to  its  occurrence.  The  tones  are 
soft  and  yielding,  and  wanting  in  their  natural  firmness  and 
stability,  so  that  various  deformities  result.  The  sides  of  the 
chest  become  flattened,  and  the  sternum  projects,  giving  rise  to 
the  "  pigeon-breast."  Xodules  or  "  beads"  form  at  the  junction 
ot  the  ribs  and  their  cartilages.  The  long,  supporting  bones 
become  bent  and  their  epiphyseal  extremities  enlarged.  The 
soft  and  deformed  bones  are  especially  liable  to  green-stick  frac- 
tures. The  lower  jav:  is  narrow  and  dentition  is  delayed.  The 
teeth  may  decay  and  fall  out  soon  after  their  appearance.  The 
head  appears  large  ;  its  summit  is  flat ;  the  fontanels  close  late. 
Imperfect  ossification  of  the  cranial  bones  gives  rise  to  so-called 
cranio-tabes,  with  "  parchment-crackling."  The  deformities  are 
maintained  by  the  ultimate  hardening  of  the  aff'ected  bones. 

Eachitic  children  present  a  pasty  complexion  and  pearly  con- 
junctivae ;  they  are  undersized  and  poorly  resist  disease.  They 
are  restless,  and  display  a  tendency  to  excessive  sweating  of  the 
head.  Often  there  are  diflTuse  soreness  of  the  l)ody  and  slight 
elevation  of  temperature.     Digestion  is  impaired;  the  abdomen 


118  ESSENTIALS    OF    DIAGNOSIS. 

is  often  protuberant.  Laryngismus  stridulus  and  convulsions 
are  common  occurrences.  Internal  viscera  may  be  enlarged  as 
a  result  of  hyperplasia  of  the  interstitial  connective  tissue. 

Mollities  Ossium. 

What  are  the  clinical  manifestations  of  mollities  ossium? 

Mollities  ossium  is  a  morbid  condition  that  develops  in  adults 
amid  unfavorable  hygienic  surroundings  and  in  women  that 
have  borne  many  children.  It  manifests  itself  by  both  soften- 
ing and  rarefaction  of  the  bones,  so  that  progression  is  impos- 
sible, and  fractures  are  common.  Occasionally  febrile  symptoms 
are  present.  Death  is  the  common  result,  either  from  exhaus- 
tion, or  from  mechanical  interference  with  respiration. 

How  are  rachitis  and  mollities  ossium  to  be  differentiated  ? 

Mollities  ossium  is  a  disease  of  adult  life,  attended  by  changes 
in  developed  bone,  and  usually  of  fatal  termination.  Eachitis 
is  essentially  a  disease  of  childhood,  dependent  upon  abnormali- 
ties in  developing  bone,  and  from  which  recovery  usually  takes 
place,  only  the  sequels  of  the  disease  remaining. 

THE  HEART. 

Inspection. 

What  can  be  learned  of  the  heart  by  inspection  ? 

On  inspecting  the  normal  chesty  one  perceives  in  the  left  fifth 
intercostal  space,  "two  inches  below  and  an  inch  within  the  nip- 
ple, in  an  area  of  perhaps  an  inch  in  diameter,  a  gentle  rise 
and  fall — the  cardiac  impulse  or  apex-heat.  It  is  less  distinctly 
visible  in  fat  than  in  lean  persons. 

The  position  of  the  apex-beat  varies  slightly  with  the  respira- 
tory movements,  with  posture,  and  with  the  state  of  the 
abdominal  viscera.  It  may  be  displaced^  as  to  the  left  by  an 
effusion  in  the  right  pleural  cavity,  or  by  adhesions  of  the  left 
pleura  ;  or  to  the  right  by  an  effusion  in  the  left  pleural  cavity, 
or  by  adhesions  of  the  right  pleura.      It  may  be  increased  in 


PALPATION  —  PERCUSSION.  119 

extent,  as  when  the  lie.irt  is  cnlars^ed,  or  when  the  pericardium 
is  distended  with  tiuid.  Under  varying  conditions  an  impulse 
is  seen  in  tlie  epigastrium. 

The  impulse  may  be  strong,  as  in  cases  of  cardiac  hypertrophy  ; 
feeble,  as  in  cases  of  dilatation  ;  wavij,  as  when  the  pericardial 
cavity  is  occupied  by  fluid  ;  when  the  pericardium  is  adherent 
"systolic  dimpling"  occurs. 

Palpation. 

What  is  to  be  learned  of  the  heart  by  palpation  ? 

Palixttion  confirms  and  reinforces  what  is  learned  by  inspec- 
tion. An  impulse  that  cannot  be  seen  can  sometimes  be  felt. 
A  feeble  impulse  indicates  that  the  action  of  the  heart  has  been 
embarrased  by  disease  or  by  an  effusion  in  the  pericardial 
cavity ;  a  strong  impulse  is  indicative  of  over-action,  of  hyper- 
trophy. A  pericardial  friction-rub  raay-sometimes  be  felt.  In 
most  cases  of  mitral  valvular  obstruction,  and  in  some  of  aortic 
insufficiency,  a,  puiring  tremor  is  perceived  on  palpation. 

Percussion. 

What  is  to  be  learned  of  the  heart  by  percussion  ? 

By  percussion — which  is  best  practised  with  the  patient  re- 
cumbent—the approximate  size  of  the  heart  can  be  learned.  A 
considerable  portion  of  the  organ  is  covered  by  lung-tissue.  By 
superficial  percussion  of  a  normal  chest  the  cardiac  dulness  is 
found  to  be  represented  by  a  triangle  included  between  a  point 
at  the  lower  margin  of  the  fourth  left  costal  cartilage  at  its 
iunction  with  the  sternum,  another  at  the  apex-beat,  and  a  third 
at  the  lower  extremity  of  the  sternum  at  its  left  border.  Deep 
percussion  defines  a  somewhat  more  extended  area. 

The  area  of  cardiac  percussion-dulness  is  increased  when  the 
heart  is  enlarged,  or  the  pericardial  sac  is  distended  by  fluid, 
when  the  heart  is  uncovered  by  retraction  of  the  lung,  or  in  full 
expiration.  The  area  is  dimimslied  when  the  heart  is  covered 
by  emphysematous  lung-tissue,  or  by  the  lungs  in  full  inspira- 
tion. 


120  ESSENTIALS    OF    DIAGNOSIS. 


Auscultation. 

What  is  to  be  learned  of  the  heart  by  auscultation  ? 

Auscultation  constitutes  the  most  importaut  method  of  physi- 
cal examination  of  the  heart.  It  reveals  the  frequency,  the 
rhythm,  the  quahty,  and  the  purity  of  the  heart-sounds. 

In  health,  the  heart  of  an  adult  at  rest  beats  about  seventy- 
two  times  to  the  minute.  The  frequency  of  action  varies  with 
the  degree  of  bodily  exertion,  and  with  posture.  It  is  increased 
by  exertion  and  by  excitement,  after  meals,  in  febrile  atiections 
and  in  many  diseases  of  the  heart ;  it  is  greater  in  the  upright 
than  in  the  horizontal  posture  ;  it  is  diminished  by  rest  and  by 
jaundice  ;  in  aortic  obstruction,  in  fatty  degeneration  and  dur- 
ing convalescence  from  acute  disease.  It  is  affected  by  various 
drugs  and  by  nervous  influences. 

The  action  of  the  heart  in  health  is  rJtythmical  and  regidar. 
There  is  a  prolonged,  dull,  first  sound^  and  a  shorter, 
sharper  second  sowid,  followed  by  an  interval  of  silence — with 
rhythmical  repetitions.  Occasionally  a  cycle  is  omitted — the 
heart  intermits.  A  normal  first  sound  may  be  followed  by  two 
second  sounds — duplication.  The  first  sound  may  likewise  be 
duplicated.  The  normal  rhythm  of  the  heart  may  be  disturbed 
by  organic  disease  of  the  heart,  such  as  degeneration  by  func- 
tional or  nervous  disorder,  and  by  derangement  of  other  organs, 
as  of  the  stomach. 

The  first  sound  of  the  normal  adult  heart  is  a  dull,  but  well- 
defined  thud  ;  the  second  is  a  shorter,  sharper,  snapping  or  ring- 
ing sound  ;  it  is  followed  by  an  interval  of  silence.^ 

Three  elements  enter  into  the  production  of  the  first  sound, 
which  is  synchronous  with  the  contraction  of  the  ventricles 
{systole)  and  the  closure  of  the  auriculo-ventricular  {mitral  and 
tricuspid)  valves.  These  are  :  the  closure  of  the  valves.^  the  mus- 
cular contraction,  and  the  impact  of  the  heart  against  the  chest- 

'  There  can  likewise  be  detected  by  the  trained  ear  a  short  interval  of 
silence  between  the  first  and  second  sounds.  The  fact  is  mentioned  here 
to  avoid  misleading  the  student  in  his  further  studies  ;  but  for  practical 
purposes  this  "  minor  silence,"  as  it  is  called,  may  be  entirely  ignored. 


AUSCULTATION.  121 

wall.  The  second  sound,  which  is  synchronous  with  the  be- 
ginning of  the  diastole^  is  valvular  ;  it  is  due  to  the  quick  approxi- 
mation of  the  semilunar  flaps,  preventing  return  of  blood  through 
the  arterial  {aortic  ?ind  pulmonary)  orifices. 

The  first  sound  of  the  heart  may  be  altered  in  volume,  in  tone, 
in  duration  and  in  strength.  These  are  usually  ino'eased  perma- 
nently when  the  heart  is  hypertrophied,  and  may  be  increased 
temporarily  under  excitement  and  after  the  administration  of 
certain  drugs.  They  are  diminished  when  from  any  cause  the 
action  of  the  heart  is  enfeebled — among  such  causes  are  dilata- 
tion, degeneration,  pericardial  effusion.  The  character  of  the 
second  sound  is  largely  dependent  upon  the  tension  in  the 
arteries;  the  higher  the  tension  the  sharper  the  sound. 

The  imrity  of  the  heart-sounds  depends  upon  the  condition  of 
the  heart-muscle,  upon  the  state  of  the  blood  and  upon  the 
functional  efficiency  of  the  various  valves  and  orifices. 

The  functional  efficiency  of  the  valves  and  orifices  of  the  heart 
can  be  determined  by  a  study  of  the  sounds  of  the  heart  as 
heard  over  the  respective  parts  :  but  these  are  so  close  together 
that  points  in  the  course  of  the  blood-stream  are  selected  for 
auscultation.  That  for  the  mitral  sound  corresponds  to  the 
situation  of  the  apex-beat  ;  that  for  the  aortic,  to  the  junction 
of  the  right  second  costal  cartilage  with  the  sternum  ;  that  for 
the  tricuspid,  to  the  ensiform  cartilage  ;  and  that  for  the  pulmo- 
nary, to  the  left  second  intercostal  space  close  to  the  sternum. 

Alteration  of  the  structure  and  derangement  of  the  function 
of  the  valves  and  orifices  of  the  heart  are  revealed  by  adven- 
titious sounds,  called  rimrr)iiirs^  that  accompany  or  replace  the 
normal  sounds,  or  occur  in  the  interval  between  them.  Mur- 
murs are  often  blowing  ;  sometimes  they  are  soft,  sometimes 
harsh,  sometimes  musical. 

The  first  sound  occupies  the  ventricular  s?/stoZe ;  the  diastole 
is  taken  up  by  the  second  sound  and  the  period  of  silence.  During 
the  s3'Stole,  the  blood  pases  from  the  ventricles  into  the  aorta 
and  pulmonary  artery  ;  the  arterial  valves  should  be  freely  open  ; 
the  auriculo-ventricular  valves  should  be  perfectly  closed  :  mur- 
murs generated  at  the  arterial  orifices  indicate  obstruction  to 
the  outflow  of  blood  from  the  ventricles  ;  murmurs  generated  at 


122 


ESSENTIALS    OF    DIAGNOSIS, 


the  auriculo-ventricular  orifices  indicate  reflux  of  blood  into  the 
auricles. 

At  the  conclusion  of  the  systole,  there  is  a  brief  pause,  fol- 
lowed by  the  diastole,  during  which  the  blood  flows  from  the 
auricles  into  the  ventricles  ;  the  auriculo-ventricular  valves 
should  be  freely  open  ;  the  arterial  valves  should  be  perfectly 
closed  :  murmurs  generated  at  the  auriculo-ventricular  orifices 
indicate  obstruction  to  the  onflow  of  blood  into  the*ventricles ; 
murmurs  generated  at  the  arterial  orifices  indicate  reflux  of 
blood  from  the  arteries. 

Incompetency  or  insufficiency  of  a  valve  permits  of  regurgita- 
tion. 

Constriction  or  occlusion  of  an  orifice  occasions  obstruction. 

The  valves  and  orifices  may  be  so  altered  by  adhesion  as  to 
prevent  perfect  closure.  Under  such  conditions  both,  regurgitant 
and  obstructive  murniars  may  be  audible. 

The  seat  and  character  of  an  endocardial  murmur  are  deter- 

FiG.  19. 


Auscultation  of  the  heart-sounds.  The  small  letters  indicate  the  situation  of  the 
valves;  the  large  letters,  the  points  for  auscultation,  a^,  aortic;  ??ji)/,  mitral ;  tT, 
tricuspid;  pP,  pulmonary.     (Vierordt.) 


mined  from  thepZace  at  which  it  is  best  heard  (site  of  maximu'ni 
intensity),  in  association  with  the  time  of  its  occurrence  and  the 
direction  in  which  it  is  transmitted. 
Analogous  conditions  of  the  right  and  left  heart  necessarily  give 


AUSCULTATION.  123 

rise  to  nuiriHiirs  at  tlie  same  time  ;  analogous  conditions  of  the 
auriciilo-veulricLilar  and  arterial  valves  give  rise  to  murmurs  at 
different  times  ;  and  conversely.  Thus,  for  example,  the  mur- 
murs of  mitral  insufficiency  and  of  tricuspid  insufficiency  coin- 
cide in  time  with  each  other  and  with  the  murmurs  of  aortic 
obstruction  and  of  [)ulmonary  obstruction.  ]Mitral  and  tricuspid 
regurgitant  murmuis  and  aortic  and  pulmonary  obstructive 
murmurs  are  heard  during  the  systole— with  or  in  place  of 
the  first  sound.  Mitral  and  tricuspid  obstructive  murmurs  and 
aortic  and  pulmonar}'  regurgitant  murmurs  are  heard  during 
the  diastole ;  the  latter  two  with  or  in  place  of  the  second  sound ; 
the  first  two,  however,  in  what  is  normally  the  period  of  silence 
immediately  preceding  the  tir^^t  sound— hence  presij.-^toUc. 

Mitral  regurgitant  murmurs  are  heard  best  at  the  apex  of  the 
heart ;  the}'  are  transmitted  in  the  course  of  the  fifth  and  sixth 
ribs  to  the  axilla,  and  may  be  heard  below  the  posterior  inferior 
angle  of  the  scapula.  21itral  ohstrudive  murmurs  are  best  iieard 
at  the  apex  of  the  heart,  or  a  little  above  the  apex  ;  they  are 
-but  feebly  transmitted.  Aortic  reyimjilant  and  aortic  ohsiructive 
murmurs  are  most  distinctly  heard  at  the  junction  of  the  second 
costal  cartilage  on  the  right  with  the  sternum  ;  the  former  are 
transmitted  downwards  in  the  course  of  the  sternum  and  may 
often  be  heard  all  over  the  chest;  the  latter,  upwards  in  the 
course  of  the  great  vessels,  especially  the  carotid.  Exception- 
ally the  murmur  of  mitral  regurgitation  may  be  so  transmitted 
as  to  be  heard  at  the  aortic  cartilage ;  or  the  murmur  of  aortic 
obstruction  be  transmitted  downwards  towards  the  apex  of  the. 
heart.  Murmurs  generated  at  the  orifices  and  by  the  valves 
of  the  right  side  of  the  heart  are  exceedingly  rare.  Tricuspid 
regurgitant  and  obstructive  murmurs  are  Itest  heard  at  the  ensi- 
form  cartilage,  or  a  little  farther  to  the  right.  Pulmonary  mur- 
murs should  be  best  heard  in  the  second  intercostal  space  on  the 
left,  close  to  the  margin  of  the  sternum.  In  anemia,  soft  blow- 
ing murmurs,  dependent  upon  the  condition  of  the  blood,  are 
heard  in  the  same  situation. 

All  murmurs  heard  in  the  precordial  region  are  not  endo- 
cardial. Auscultation  reveals  as  well  the  sounds  of  pericardial 
friction  as  of  adjacent  pleural  friction. 


124  ESSENTIALS    OF    DIAGNOSIS. 

How  are  murmurs  due  to  organic  disease  to  be  distinguished 
from  so-called  functional  murmurs? 
In  addition  to  adventitious  sounds  generated  at  the  orifices 
of  the  heart  as  a  result  of  structural  changes,  nun-murs  are 
heard  when  the  condition  of  the  blood  is  deteriorated,  or  when, 
from  disturbed  action  of  the  heart  or  other  cause,  abnormal 
currents  are  generated  in  the  blood-stream.  These  so-called 
functional  murmurs  are  distinguished  by  their  inconstancy  and 
their  softness  ;  they  are  usually  heard  only  at  the  base  of  the 
heart  and  over  the  body  of  tlie  organ;  they  are  not  transmitted  ; 
they  are  intensified  by  pressure  with  the  stethoscope  ;  and  they 
disappear  with  the  removal  of  the  conditions  upon  which  they 
depend.  Organic  murmurs  are  usuall}?^  harsher,  more  constant, 
and  vary  comparatively  little  in  character  and  intensity. 

What  is  the  sphygmograph? 

The  sphygmograph  is  an  instrument  by  which  an  artery  is 
made  to  record  certain  of  the  characters  of  its  pulsation.  The 
sphygmogram  (Fig.  20)  is  an  important  aid  in  diagnosis,  but 

Fig.  20. 


Normal  pulse-traciug.     (After  Eichhorst.) 

cannot  be  relied  upon  apart  from  the  ordinary  rational  and 
physical  signs.  The  use  of  the  sphygmograph  and  the  signifi- 
cance of  its  tracings  must  be  learned  by  experience. 

Malformation. 

What  are  the  most  common  malformations  of  the  heart  ? 

The  most  common  malformations  of  the  heart  consist  in  an 
imperforate  interventricular  septum  and  a  failure  of  the  foramen 
ovale  to  close. 


FUNCTIONAL    DISTURBANCE    OF    T  II  K    HEART.     125 

To  what  symptoms  do  malformations  of  the  heart  give  rise? 

Individuals  in  wlioin  there  exist  serious  almornial  communica- 
tions between  the  lateral  halves  of  the  heart  rarely  reach  adult 
life.  Cyanosis  is  the  most  common  symptom.  Systolic  mur- 
murs are  heard  practically  indistinguishable  from  those  oc- 
casioned by  valvular  derangement. 

Dextrocardia. 

What  is  dextrocardia  ? 

Drxtrocardia  is  a  congenital  displacement  of  the  heart  on  the 
right  side,  commonly  associated  with  displacement  of  the  liver 
on  the  left  and  of  the  spleen  on  the  right. 

How  is  dextrocardia  to  be  recognized  ? 

In  case  of  dextrocardia  the  impulse  of  the  heart  is  wanting 
in  its  usual  situation,  and  is  seen  to  the  right  of  the  sternum. 
The  area  of  cardiac  percussion-dulness  occupies  on  the  right  an 
extent  corresponding  to  that  which  it  normally  occupies  on  the 
left.  The  sounds  of  the  heart  are  heard  on  the  right  side  instead 
of  on  the  left.  The  hepatic  percussion-dulness  is  not  found  in 
its  usual  situation,  but  in  a  corresponding  position  on  the  left. 
The  splenic  dulness  is  found  on  the  right  instead  of  on  the  left. 

Functional  Disturbance  of  the  Heart. 

What  is  meant  by  functional  disturbance  of  the  heart? 

Under  various  conditions,  as  when  the  nutrition  is  impaired 
or  the  digestion  is  deranged,  as  a  result  of  overwork,  or  of 
dissipation,  or  of  the  excessive  use  of  tobacco,  or  tea,  or  coffee, 
and  in  connection  with  gout  or  lithemia,  with  hysteria  or  hypo- 
chondriasis, the  action  of  the  heart  may  be  deranged  without 
recognizable  structural  change.  There  will  be  present  such 
symptoms  as  pain,  palpitation,  anxiety,  headache,  vertigo  and 
breathlessness,  sometimes  with  irregularity  and  increased 
frequency  of  the  heart's  action.  The  diagnosis  depends  upon 
the  recognition  of  the  primary  condition  and  upon  the  absence 
of  the  physical  signs  of  a  cardiac  lesion.     Functional  disorder, 


126  ESSENTIALS    OF    DIAGNOSIS. 

great  in  degree  and  long   continued,  may   lead   to   structural 
change. 

Tachycardia. 

What  is  tachycardia? 

Tachi/cardia  is  a  term  applied  to  a  somewhat  rare  condition  of 
excessive  rapidity  of  the  action  of  the  heart,  accompanied  with 
palpitation,  the  rhythm  of  the  heart  sometimes  remaining  un- 
affected. The  pulse  may  exceed  200  heats  a  minute.  Occurring 
in  paroxysms,  the  qualification  paroxysmal  is  applied.  When  no 
etiologic  lesion  is  discoverable,  the  condition  is  termed  essential 
paroxysmal  tachycardia.  The  paroxysm  usually  begins  suddenly, 
with  or  without  warning  ;  at  times  without  apparent  exciting 
cause  ;  at  other  times  seeming  to  result  from  some  such  con- 
dition as  overdistention  of  the  stomach.  Tachycardia  may  be 
due  to  temporary  paralysis  of  the  vagus  or  stimulation  of  the 
cardiac  accelerator  nerve.  Increased  cardiac  dulness  and  indefi- 
nite murmurs  may  be  observed  during  the  attack,  and  disappear 
with  subsidence  of  the  symptoms.  The  condition  may  be  un- 
attended with  other  symptoms,  and  ordinarily  does  not  shorten 
life.  It  may  be  a  part  of  other  neuroses.  It  has  been  observed 
in  women  at  the  menopause. 

How  does  tachycaidia  differ  from  angina  pectoris? 

Tachycardia  is  wanting  in  the  threatening  symptoms  of  an- 
gina pectoris— the  anxiety,  the  pain,  the  cardiac  f\iilure.  Ra- 
pidity of  the  heart's  action  and  palpitation  are  the  essential 
features  of  tachycardia  ;  while  in  angina  pectoris  the  pulse  is 
of  variable  frequency. 

How  does  tachycardia  differ  from  exophthalmic  goiter? 

Palpitation  of  the  heart  and  increased  frequency  of  the  pulse 
are  among  the  earliest  phenomena  of  exophthalmic  goiter.  Be- 
fore the  thyroid  gland  has  become  enlarged  or  the  eyeballs  pro- 
trude, the  distinction  from  tachycardia  is  not  possible.  There 
is  no  difficulty  in  the  diagnosis,  however,  when  not  only  the 
exophthalmos  and  the  goiter,  but  the  array  of  other  symptoms 
that  characterize  exophthalmic  goiter,  have  also  developed. 


BllACU  YCARDI  A IRRITABLE    HEART.  127 

Brachycardia. 

What  is  brachycardia  ? 

Unusual  infrequency  of  heart-beat  is  normal  to  some  indi- 
viduals. In  others  it  may  be  related  to  disease,  febrile,  iu(;ta- 
bolic,  toxic,  hemic,  digestive,  resi)iratory,  circulatory,  cutaneous, 
genito-urinary  or  nervous.  Sometimes  there  is  merely  a  dis- 
crepancy between  the  number  of  heart-beats  and  the  number 
of  pulse-beats. 

9 

Irritable  Heart. 

What  are  the  phenomena  of  irritable  heart  ? 

Irritable  heart  is  a  condition  originally  observed  in  soldiers  in 
active  service,  in  which  there  are  in  addition  to  increased  fre- 
quency of  the  action  of  the  heart,  often  with  disturbed  rhythm, 
recurring  attacks  of  palpitation  and  pain  in  the  precordia. 
There  are  usually  headache  and  vertigo,  especially  during  the 
paroxysms.  The  general  health  may  suffer  little  or  not  at  all. 
The  first  sound  may  be  short  and  sharp  or  may  be  barely 
audible  ;  the  second  sound  is  accentuated.  There  is  no  constant 
murmur.  The  pulse  is  compressible  and  easily  influenced  by 
position.  Eespiration  is  but  little  if  at  all  accelerated.  A  simi- 
lar condition  may  develop  in  civil  life  in  those  unaccustomed  to 
arduous  labor  called  upon  to  perform  unusual  tasks.  It  has  also 
been  found  in  athletes  and  others  who  have  committed  excesses 
in  physical  exertion,  and  in  masturbators.  Under  proper  regi- 
men, restoration  to  the  normal  results  ;  under  other  circum- 
stances, hypertrophy  of  the  heart  develops. 

How  does  irritable  heait  differ  from  tachycardia? 

Irritable  heart  results  from  well-recognized  causes  that  are 
not  concerned  in  tachycardia.  In  irritable  heart  the  frequency 
is  less  than  in  tachycardia,  and  is  habitual  ;  in  tachycardia  the 
increased  frequency  is  extraordinary  and  usually  occurs  in 
parox3'sms.  It  is  pain  and  palpitation  rather  than  increased 
frequency  of  action  that  marks  the  paroxysmal  seizures  of 
irritable  heart.  Tachycardia  is  also  wanting  in  the  distressing 
subjective  sensations  and  the  grave  issue  of  irritable  heart. 


128  ESSENTIALS    OF    DIAGNOSIS. 


Angina  Pectoris. 

What  are  the  characteristics  of  angina  pectoris? 

Awjina  pectoris  is  a  paroxysmal  disorder  for  which  do  definite 
structural  lesion  has  been  found.  Perhaps  the  most  common 
condition  associated  with  it  is  atheroma  of  the  coronary 
arteries. 

The  attack  sets  in  suddenly,  with  a  sense  of  oppression,  dys- 
pnea, and  pain  in  the  precordia,  rising  to  a  high  pitch  of  inten- 
sity, and  attended  with  a  sense  of  impending  dissolution — and 
not  uncommonly  death  does  occur  in  the  paroxysm.  There  is 
often  a  sensation  as  of  throttling.  The  jmin  in  the  heart  is  de- 
scribed as  "  clutching,"  "  squeezing," and  "  tearing."  The  pain 
radiates  in  various  directions  from  the  heart,  especially  to  the 
left  shoulder,  and  extends  down  the  left  arm.  The  face  is  pale, 
the  features  drawn,  the  pulse  variable.  The  attacks  may  occur 
spontaneously,  but  are  usually  brought  on  by  excitement  or 
exertion,  or  by  gastro-intestinal  derangement.  They  recur  with 
varying  frequency,  sometimes  over  a  long  period  of  years.  The 
disease  is  most  common  in  men  in  advanced  middle  life. 

How  does  intercostal  neuralgia  differ  from  angina  pectoris? 

The  pain  of  intercostal  neuralgia  never  attains  the  intensity 
or  presents  the  peculiar  character  of  that  of  angina  pectoris  ;  nor 
are  the  general  manifestations  ever  so  portentous.  The  tender 
points  of  Yalleix,  found  in  intercostal  neuralgia,  are  absent  in 
angina  pectoris.  An  herpetic  eruption  on  the  chest,  following 
the  course  of  an  intercostal  nerve,  is  diagnostic  of  neuralgia. 

Hypertrophy. 

What  are  the  symptoms  of  hypertrophy  of  the  heart? 

The  size  of  the  heart  is  proportionate  to  the  demands  made 
upon  it,  or  to  the  stimulation  that  it  receives.  Valvular  disease 
and  other  conditions  impeding  the  circulation  may  cause  one  or 
all  of  the  cardiac  chambers  to  enlarge  and  the  walls  to  thicken. 
Hypertrophy,  uncomplicated  by  valvular  disease,  results  when 
the  heart  is  called  upon  to  perform  excessive  labor,  or  is  stimu- 


DILATATION.  129 

lated  by  abnormal  nervous  influences.  Symptoms  arise  only 
when  the  action  of  the  heart  is  in  excess  of  the  requirements  of 
the  system.  Under  such  conditions  there  will  be  a  sense  of  dis- 
comfort in  the  precordial  region,  palpitation,  paroxysmal  cough, 
shortness  of  breath,  headache,  vertigo,  ringing  in  the  ears,  dis- 
turbed sleep,  deranged  digestion,  a  florid  complexion,  and  a 
tendency  to  hemorrhage. 

What  are  the  physical  signs  of  hypertrophy  of  the  heart? 

When  the  heart  is  hypertrophied^  its  impulse  is  decided  and  ex- 
tended, and  usually  displaced  to  the  left.  The  area  of  per- 
cussion-didness  is  increased.  As  the  enlargement,  in  most  cases, 
principally  involves  the  left  ventricle,  the  area  of  dulness  in- 
creases to  the  left,  though  enlargement  of  the  left  ventricle  is 
likely  to  be  followed  in  turn  by  hypertrophy  of  the  remaining 
cavities.  Owing  to  the  position  of  the  heart  in  the  chest,  the 
left  ventricle  may  be  moderately  enlarged  without  giving  rise 
to  appreciable  percutory  abnormality.  Enlargement  of  the 
right  heart  may  be  the  first  cause  of  extension  of  the  area  of  dul- 
ness. The  action  of  the  heart  is  moderately  accelerated,  regular 
and  rhythmical.  The  first  sound  is  strong  and  booming,  the  second 
accentuated.     The  pulse  is  correspondingly  full  and  strong. 

Dilatation. 

What  are  the  symptoms  of  dilatation  of  the  heart? 

Dilatation  of  the  heart  occurs  under  pretty  much  the  same  con- 
ditions as  give  rise  to  hypertrophy,  except  that  the  organ  is 
unable  to  meet  the  demands  made  upon  it.  Dilatation  may 
thus  be  a  sequel  of  hypertrophy.  As  dilatation  is  frequently 
an  ultimate  result  of  obstruction  to  the  pulmonary  circulation, 
the  right  heart  usually  suffers  the  more.  The  symptoms  are 
tho&e  of  failing  circidation :  precordial  anxiety,  palpitation,  head- 
ache, vertigo,  syncope,  pallor,  cough,  dyspnea,  venous  conges- 
tion, and  dropsy. 

What  are  the  physical  signs  of  dilatation  of  the  heart  ? 

The  cardiac  impulse  is  feeble  and  diflused,  and  usually  dis- 
placed to  the  left.     The  area  of  cardiac  p^rcussion-dulnes^  is  iu^ 
9 


130  ESSENTIALS    OF    DIAGNOSIS. 

creased.  The  first  sound  is  weakened  in  correspondence  with 
the  disproportion  between  the  enlargement  of  the  cardiac  cliam- 
bers  and  the  thickness  of  their  walls;  the  second  is  little  changed. 
If  the  dilatation  has  been  great  enough  to  so  enlarge  the  orifices 
or  weaken  the  muscles  that  the  valves  are  no  longer  competent 
to  effect  complete  closure,  regurgitant  murmurs  may  be  devel- 
oped, even  in  the  absence  of  structural  alterations  in  the  valves. 
Such  murmurs  are  usually  rather  soft  and  may  be  inconstant. 
The  action  of  the  heart  may  be  rapid  and  irregular.  The  j^ulse 
is  small  and  soft. 

What  are  the  distinctions  between  hypertrophy  and  dilatation 
of  the  heart  ? 

HYPERTROPHY.  DILATATION. 

Face  florid  ;  ringing  in  ears  ;  rush-  Face  pallid  ;  tendency  to  63'ncope  ; 

ing  of  blood  to  the  head.  dropsy. 

Cardiac  impulse  strong,  extensive.  Impulse  feeble,  diffused,  often  wavy. 

Increased  area  of  percussion-dul-  Increased  area  of  percussion-dul- 

ness.  ness. 

Action  rapid,  regular,  rhythmical.  Action  rapid,  irregular. 

First  sound  strong.  First  sound  relatively  enfeebled. 

Pulse  full,  strong.  Pulse  small,  yielding. 

How  does  dilatation  of  the  heart  differ  from  fatty  degeneration 
of  the  heart  ? 

Fatty  degeneration  of  the  heart  may  be  recognized  when  the 
skin  has  a  peculiar,  greasy  appearance,  when  an  arcus  senilis  is 
present,  when  the  sounds  of  a  heart  not  enlarged  are  exceed- 
ingly feeble,  and  attended  with  the  symptoms  of  a  failing 
circulation.  It  differs  from  dilatation  in  the  unchanged  or 
diminished  size  of  the  heart  and  the  association  with  such 
other  evidences  of  fatty  degeneration  as  may  be  present.  The 
pulse  is  usually,  but  not  invariably,  slow  in  fatty  degeneration, 
while  it  is  rapid  in  dilatation. 

How  is  a  pericardial  effusion  to  be  distinguished  from  dilata- 
tion of  the  heart  ? 
Fluid  may   collect   in   the   pericardium  in  connection  with 
pericarditis,  or  as  a  part  of  a  general  dropsy.     In  dilatation  of 
tUQ  heart  the  cardiac  impulse  is  feeble  and  diffuse,  but  not  as 


VALVULAR    DISEASE.  131 

feeble  or  as  wavy  as  in  effusion.  When  dilatation  exists,  the 
percussion-dulncss  in  the  precordia  is  not  as  extensive  as  when 
there  is  an  efl'usion,  nor  is  it  peculiarly  triangular  in  outline. 
While  the  sounds  of  the  heart  are  enfeebled  over  the  organ 
when  dilatation  exists,  the}'  are  almost  obliterated  in  case  of 
effusion,  except  at  the  base,  where,  in  case  of  pericarditis, 
friction-sounds  may  likewise  be  detected.  The  recognition  of 
a  condition  that  gives  rise  to  pericardial  effusion  is  an  aid  in 
diagnosis. 

Valvular  Disease. 

What  are  the  symptoms  common  to  valvular  lesions  of  the 
heart  ? 

The  functional  deficiency  of  a  diseased  heart-valve  may  be 
compensated  for  b}'  an  improved  condition  of  the  heart-muscle. 
The  presence  or  absence  of  rational  signs  will  depend  upon  the 
extent  and  constancy  of  the  structural  and  functional  alteration 
of  the  muscle.  If  the  alteration  be  too  great,  the  symptoms 
will  be  those  of  an  hypertrophied  or  overacting  heart.  If  it  be 
too  little,  the  s}- mptoms  will  be  those  of  an  enfeebled  heart.  If 
it  be  inconstant,  symptoms  of  excitement,  of  overaction  or  of 
enfeeblement  may  appear  in  paroxysms,  or  for  prolonged  pe- 
riods at  irregular  intervals.  Even  w^hen  the  compensatory 
change  is  apparently  constant  and  sufficient,  there  may  be  at 
times  or  continuously,  with  or  without  pallor  and  weakness,  a 
sense  of  precordial  discomfort,  palpitation  of  the  heart,  short- 
ness of  breath,  perhaps  headache  and  vertigo — all  aggravated 
by  exertion.  Often,  when  compensation  is  but  slightly  imper- 
fect, there  are  evidences  of  gastric  and  intestinal  derangement, 
and  a  sense  of  fulness  in  the  h3'pochondria.  Should  the  heart 
fail,  and  compensation  be  disturbed,  the  condition  becomes  vir- 
tually or  actuall}'  that  of  dilatation  of  the  heart ;  the  phenomena 
are  those  of  insufiicieut  vis  a  tergo  in  the  circulation.  As  a  re- 
sult of  the  stagnation  of  blood  in  the  veins,  there  is  engorge- 
ment  of  various  organs,  especially  of  the  lungs,  liver,  kidneys  and 
spleen ;  the  existing  s^-mptoms  become  intensified,  and  in  addi- 
tion there  appears  dropsy,  first  manifesting  itself  in  the  lower 
extremities,  and  extending  upwards. 


132  ESSENTIALS    OF    DIAGNOSIS. 

When  two  or  more  lesions  coexist,  the  compensation  is  less 
readily  established  and  more  easily  ruptured  than  in  the  case 
of  single  lesions.  Pulmonary  congestion  and  hemoptysis  occur 
not  infrequently. 

Mitral  Incompetency— Mitral  Eegurgitation. 

What  are  the  signs  of  incompetency  of  the  mitral  valve 
(mitral  regurgitation)  ? 

As  a  result  of  endocarditis,  or  of  fibrous  or  calcareous  degen- 
eration, the  bicuspid  leaflets,  or  the  chordae  tendinea,  become 
thickened  and  contracted,  interfering  with  the  accurate  apposi- 
tion of  the  segments  of  the  mitral  valve  during  the  systole. 
Sometimes  a  similar  result  is  brought  about  by  dilatation  of  the 
left  side  of  the  heart  and  of  the  mitral  orifice.  In  consequence, 
blood  is  abnormally  diverted  backward  through  the  mitral  ori- 
fice, giving  rise  to  a  blowing  (systolic)  sound,  heard  with  greatest 
distinctness  at  the  apex,  and  transmitted,  in  the  course  of  the 
fifth  and  sixth  ribs,  to  the  axilla  and  to  the  inferior  angle  of 
scapula.  The  heart  is  usually  enlarged — under  favorable  con- 
ditions, hypertrophied  ;  under  unfavorable  conditions,  dilated. 
The  pulmonary  second  soimd  is  usually  accentuated. 

Mitral  Obstruction. 

What  are  the  physical  signs  of  obstruction  at  the  mitral 
orifice  ? 

The  mitral  orifice  becomes  contracted  as  a  result  of  endocar- 
ditis or  of  degenerative  changes  in  the  segments  of  the  valve. 
The  characteristics  of  mitral  obstruction  are :  a  rumbling 
murmur  heard  just  before  the  systole,  with  greatest  intensity 
over  the  left  ventricle,  and  a  purring  tremor  or  thrill  perceived 
by  the  hand  placed  over  the  precordia.  The  first  sound  is  short 
and  sharp,  often  resembling  the  second  sound ;  and  the  pulmo- 
nary second  sound  accentuated.  The  left  ventricle  diminishes 
in  size,  while  the  left  auricle  becomes  enormously  enlarged.  In 
turn  the  right  side  of  the  heart  becomes  enlarged.  The  pulse 
is  small  and  feeble.  Not  rarely  mitral  incompetency  is  asso- 
ciated with  obstruction. 


AORTIC    OBSTRUCTION.  133 


Aortic  Obstruction. 

What  are  the  physical  signs  of  aortic  obstruction  ? 

Aortic  obstruction  is  a  result  of  structural  changes  in  the 
semilunar  valves  or  in  the  aorta,  induced  by  inflammation  or 
degeneration.  Aortic  obstruction  and  incompetency  are  often 
associated.  The  action  of  the  heart  is  strong  ;  the  left  ventricle 
becomes  hypertrophied  ;  the  pulse  may  be  full  and  strong  or 
small  and  tardy.  Occasionally  a  systolic  thrill  can  be  felt  at 
the  base  of  the  heart  on  the  right.  At  midsternuni  and  on 
the  right  side  over  the  junction  of  the  second  costal  cartilage 
with  the  sternum,  a  coarse,  blowing,  systolic  murmur  is  heard, 
transmitted  into  the  great  vessels.  The  murmur  of  aortic  ob- 
struction is  sometimes  to  be  heard  over  the  right  carotid  artery, 
when  at  midsternum  and  at  the  aortic  cartilage  merely  an  ob- 
scuration of  the  first  sound  can  be  detected. 

Aortic  obstruction,  apart  from  insufficiency,  is  one  of  the  less 
common  lesions.  A  systolic  murmur  heard  at  the  aortic  carti- 
lage and  transmitted  into  the  neck  may  be  due  to  dilatation  ox 
roughening  of  the  aorta,  without  valvular  or  orificial  change, 
and  may  give  rise  to  no  circulatory  disturbance. 


Aortic  Incompetency— Aortic  Regurgitation. 

What  are  the  physical  signs  of  incompetency  of  the  aortic 
valve  (aortic  regurgitation)  ? 
Aortic  incompetency  arises  from  conditions  similar  to  those 
that  give  rise  to  imperfections  at  the  other  orifices  of  the  heart, 
as  well  as  from  atheromatous  changes.  It  is  often  associated 
with  aortic  obstruction.  It  is  characterized  by  a  blowing,  dia- 
stolic murmur,  replacing  or  accompanying  the  second  sound 
of  the  heart,  heard  with  greatest  intensity  at  the  aortic  cartil- 
age, and  transmitted  downwards  in  the  course  of  the  sternum. 
The  action  of  the  heart  is  powerful ;  the  left  ventricle  becomes 
enormously  dilated  and  hypertrophied;  vascular  pulsation  is 
common  and  may  be  evident  even  in  parts  remote  from  the 
center  of  circulation,  as  the  dorsal  artery  of  the  foot;  the  pulsa- 


134  ESSENTIALS    OF    DIAGNOSIS. 

tion  in  the  carotids  may  be  so  strong  that  the  head  is  shaken  ; 
the  pulse  comes  up  well  with  the  systole  of  the  heart,  but  im- 
mediately recedes — constituting  the  gaseous  pulse,  also  called 
the  water-hammer  pulse,  or  tlie  pulse  of  Corrigan.     This  char- 

FiG.  21. 


Pulse-tracing  of  aortic  insufficiency.    (After  ytriimpeli.) 

acter  is  well  shown  in  the  sphygmographic  tracing.  (Fig.  21.) 
Sometimes  a  thrill  can  be  felt  and  a  presystolic  murmur  heard 
over  the  heart. 

Tricuspid  Incompetency — Tricuspid 
Regurgitation. 

What  are  the  signs  of  tricuspid  regurgitation  (incompetency 
of  the  tricuspid  valve)  ? 

Lesions  of  the  valves  and  orifices  of  the  right  side  of  the 
heart  are  uncommon.  They  may  be  congenital,  or  due  to 
endocarditis,  although  they  more  commonly  follow  disease  of 
the  left  side  of  the  heart  and  disease  of  the  lungs. 

If  the  tricuspid  valve  is  incompetent,  blood  regurgitates  with 
the  contraction  of  the  ventricle  ;  in  consequence,  a  blowing 
systolic  murmur  is  heard  at  the  ensiform  cartilage,  and  sj^stolic 
pulsation  is  visible  in  the  veins  of  the  neck.  In  some  cases  the 
hver  is  seen  to  pulsate. 


ACUTE   PERICARDITIS.  135 


Tricuspid  Obstruction. 

What  are  the  signs  of  obstruction  at  the  tricuspid  orifice  ? 

When  the  tricuspid  orifice  is  obstructed  the  blood  must 
accumulate  in  the  peripheral  veins  ;  a  presystolic  murmur  is 
heard  at  the  ensiform  cartilasje. 


Pulmonary  Obstruction. 

What  are  the  signs  of  obstruction  at  the  pulmonary  orifice  ? 

When  the  puhnonar}^  orifice  is  obstructed  a  systolic  murmur 
is  heard  in  the  third  intercostal  space  on  the  left,  close  to  the 
sternum. 

Pulmonary  Incompetency — Pulmonary  Kegur- 

gitation. 

What  are  the  signs  of  incompetency  of  the  pulmonary  valve 
(pulmonary  regurgitation)  ? 

When  the  pulmonary  valve  is  incompetent  regurgitation  occurs 
with  the  dilatation  of  the  ventricle  ;  as  a  result  a  diastolic  mur- 
mur is  heard  at  the  junction  of  the  third  costal  cartilage  on  the 
left  with  the  sternum  ;  the  murmur  may  be  transmitted  down- 
Avards  in  the  course  of  the  sternum.  The  vascular  phenomena 
attending  aortic  insufliciency  are  wanting. 

Acute   Pericarditis. 

What  are  the  distinguishing  features  of  acute  pericarditis  ? 

Acute  pericarditis  may  develop  in  association  with  rheuma- 
tism, infectious  diseases,  nephritis,  or  pleurisy,  endocarditis,  or 
other  adjacent  disease;  it  may  also  result  from  exposure  to  cold 
or  from  blows  upon  the  chest.  It  is  attended  with  pain  in  the 
precordial  region,  and  sometimes  in  the  epigastrium  ;  consider- 
able elevation  of  temperature  and  other  febrile  symptoms  ;  a 
sense  of  anxiety  ;  dyspnea  ;  irregularity  and  increased  rapidity 
of  the  heart ;  irritable  cough  ;  possibly  headache,  vertigo,  deli- 


136 


ESSENTIALS    OF    DIAGNOSIS. 


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ACUTE    PERICARDITIS.  137 

rium,  nausea,  ami  vomiting.  The  gastric  phenomena  may  ob- 
scure the  actual  condition,  or  the  cerebral  symptoms  may  sug- 
gest meningitis  ;  careful  inquiry  and  examination  will,  however, 
reveal  the  inflammation  of  the  pericardium. 

What  are  the  physical  signs  of  acute  pericarditis  ? 

In  the^'/'st  stage^  the  characteristic  sign  is  a  rubbing /nc^?*07i- 
sound  heard  close  to  the  ear  at  one  or  more  points  in  the  pre- 
cordia,  synchronously  with  one  or  both  sounds  of  the  heart. 
The  sound  is  to  be  distinguished  from  an  endocardial  murmur 
by  its  quality,  its  superficiality  and  by  increase  of  distinctness 
caused  by  pressure  with  the  stethoscope. 

In  the  second  stage— that  of  effusion,  a  murmur  is  no  longer 
heard,  except  perhaps  above  the  fluid  at  the  origin  of  the  great 
vessels.  The  exudation  may  be  sero-fibrinous,  hemorrhagic  or 
purulent.  The  cardiac  impulse  is  feeble,  extended  and  wavy. 
The  area  of  jjercussion-didness  is  increased,  and  presents  a  pecu- 
liar outline— being  triangular,  with  the  base  below.  At  the  apex 
and  over  the  body  of  the  heart,  the  sounds  are  heard  but  feebly 
or  not  at  all,  while  at  the  base  they  may  be  heard  with  ordinary 
distinctness. 

In  the  third  stage,  the  fluid  has  disappeared,  and  murmurs 
may  again  be  heard.  In  the  course  of  time,  however,  the 
opposite  surfaces  of  the  inflamed  membrane  become  adherent, 
so  that  the  pericardial  cavit}^  is  in  whole,  or  in  part,  obliterated. 
Adhesions  to  the  chest-wall  give  rise  to  localized  retraction, 
and  to  systolic  dimpling.     The  heart  in  turn  becomes  enlarged. 

Diaphragmatic  adhesions  may  cause  visible  sj'stolic  tugging 
at  points  where  the  diaphragm  is  attached. 

How  are  acute  pericarditis  and  acute  pleurisy  to  be  differ- 
entiated ? 
Pericarditis  and  pleuritis  arise  under  similar  conditions. 
The  two  ma}^  be  associated.  The  physical  phenomena  of  both 
are  analogous,  differing,  however,  in  degree,  extent  and  situa- 
tion. The  friction-sound  of  pleurisy  is  heard  synchronously 
with  the  respiratory  movements,  that  of  pericarditis  synchron- 
ously with  the  cardiac  movements— the  latter  is  thus  the  more 
frequent.     If  doubt  arise,  the  breathing  should  be  suspended 


138  ESSENTIALS   OP    DIAGNOSIS. 

for  a  short  time  :  a  pleural  friction  disappears.  The  percussion- 
duliiess  occasioned  by  an  effusion  into  the  pericardium  is  situ- 
ated in  the  precordia,  and  has  a  characteristic  triangular  out- 
line ;  the  percussion-dulness  of  an  effusion  into  the  pleural  cavity 
involves  the  lateral  and  posterior  aspects,  as  well  as  the  anterior 
aspect  of  the  chest. 

Diseases  of  the  Myocardium. 

What  are  the  most  common  affections  of  the  myocardium  ? 

The  myocardium  may  undergo  degenerative  change  in  con- 
sequence of  interference  vv^ith  the  blood-supply  through  the 
coronary  arteries ;  of  alterations  in  the  quality  of  the  blood 
from  deliciency  of  red  cells  or  of  coloring  matter,  or  from  the 
presence  of  toxic  substances  in  association  wdth  or  independ- 
ently of  infectious  diseases ;  of  adjacent  disease ;  and  of  high 
bodily  temperature.  In  obese  persons  there  may  also  be  an 
increased  deposit  of  fat  upon  or  in  the  myocardium.  Interfere 
ence  with  the  supply  of  blood  through  the  coronary  arteries 
may  give  rise  to  anemic  necrosis,  possibly  with  aiieurismal  for- 
mation and  rupture,  or  even  the  development  of  an  abscess,  and 
to  fibrosis  of  the  myocardium.  General  anemia  may  csmse  fatty 
degeneration  of  the  muscular  structure  of  the  heart;  as  may  also 
some  toxic  processes,  while  others  cause  fibrosis.  Parenchyma- 
tous degeneration  is  usually  the  result  of  some  toxic  process  or 
of  infectious  disease,  and  myocarditis  is  usually  present  with 
endocarditis  and  pericarditis.  Fragmentation  and  segmentation 
may  attend  other  forms  of  myocardial  disease.  Among  other 
morbid  processes  that  may  attack  the  myocardium  are  broivn 
atrophy,  amyloid  degeneration,  hyaline  transformation  and  calcare- 
ous degeneration.  The  heart  may,  further,  be  the  seat  of  syphilis, 
of  tuberculosis  and  of  new-growths. 

What  are  the  most  conspicuous  symptoms  of  disease  of  the 
myocardium? 

Disease  of  the  myocardium  may  be  unattended  with  symp- 
toms, and  sudden  death  may  occur.  During  life  the  action  of 
the  heart  may  be  enfeebled  and  slow,  the  rhythm  disturbed, 
even  to  intermittence,  and  precordial  distress,  palpitation, 
dyspnea,  vertigo  and  edema  be  present. 


ACUTE   ENDOCARDITIS.  139 


Acute  Endocarditis. 

What  are  the  characteristics  of  acute  endocarditis  ? 

Acute  endocarditis  develops  in  the  course  of  various  infec- 
tious diseases  and  of  nephritis  and  chorea,  but  more  espe- 
cially in  connection  with  acute  rheumatism  and  other  vari- 
eties of  arthritis.  It  is  not  rare  in  connection  with  tonsillitis 
and  specific  urethritis.  It  may  be  engrafted  upon  pre-existing 
chronic  endocarditis.  It  may  be  simple  or  vegetative,  or  ma- 
lignant or  ulcerative.  The  valves  of  the  heart  are  more  often 
affected  than  its  walls.  The  disease  is  characterized  by  a  sense 
of  distress  in  the  precordia,  palpitation  and  increased  frequency 
of  action  of  the  heart,  sometimes  with  irregularity,  elevation 
of  temperature,  dyspnea,  slight  cough  and  an  anxious  expres- 
sion. In  addition,  the  face  may  be  flushed ;  there  may  be  chills, 
headache,  vertigo,  delirium,  icterus,  irritability  of  the  stomach, 
and  diarrhea.  Finally,  symptoms  of  embolism  in  various  parts 
of  the  body  may  appear.  The  characteristic  sign  of  acute  endo- 
carditis is  a  soft,  blowing,  systolic  murmur,  though  it  is  possible 
for  endocarditis  to  exist  without  the  detection  of  a  murmur. 
The  occurrence  of  intermittent  fever  in  a  case  of  chronic  endo- 
carditis should  awaken  suspicion  of  its  ulcerative  character. 

How  is  the  murmur  of  an  acute  endocarditis  to  be  distinguished 
from  a  murmur  the  result  of  a  past  endocarditis  ? 

The  murmur  of  acute  endocarditis  is  soft,  inconstant  in  its 
seat,  unattended  with  enlargement  of  the  heart  and  associated 
with  the  fever,  precordial  anxietj^  and  other  sjnnptoms  of  acute 
endocarditis  ;  a  murmur  dependent  upon  a  past  endocarditis  is 
harsher,  fixed  in  seat,  unattended  with  fever,  but  associated 
with  cardiac  enlargement  and  a  history  of  one  of  the  conditions 
that  may  cause  endocarditis  or  of  a  remote  attack  of  endo- 
carditis. 

ACUTE  ENDOCARDITIS.  CHRONIC   VALVULAR   DISEASE. 

The  murmur  is  soft  and  iuconstant  The  murmur  is  harsher,  fixed  in 

in  seat  and  occurrence.  seat  and  constant  in  occurrence. 

Unattended  with   enlargement  of  Attended  with  enlargement  of  the 

the  heart.  heart. 


140  ESSENTIALS    OP    DIAGNOSIS. 

ACUTE  ENDOCARDITIS.  CHRONIC  VALVULAR  DISEASE. 

Associated  with  fever,  precordial  Not  associated  with  fever  or  other 

anxiety  and  other  symptoms  of  symptoms  of   an    acute    condi- 

acute  endocarditis.  tion. 

No  history  of  a  remote  acute  endo-  Remote  history  of  acute  endocar- 

carditis.  ditis. 

Associated    with    rheumatism    or  Absence  of  an  immediate  cause  of 

other  cause   of  acute   endocar-  acute  endocarditis. 

ditis. 

How  is  acute  endocarditis  to  be  distinguished  from  acute  peri- 
carditis ? 

The  paio  of  pericarditis  is  likely  to  be  more  severe  than  that  of 
endocarditis.  The  murmur  of  pericarditis  appears  closer  to  the 
ear  than  that  of  endocarditis  ;  the  former  is  a  friction-sound, 
diastolic  as  well  as  systolic  ;  the  latter  is  blowing;  in  character 
and  only  systolic.  When  a  pericardial  effusion  exists,  it  presents 
a  peculiar  area  of  dulness  on  percussion,  the  heart-sounds  at  the 
apex  are  enfeebled  or  they  may  be  absent,  and  there  is  a  dif- 
used,  feeble  and  wavy  impulse,  not  found  in  endocarditis. 

How  are  a  pericarditic  and  a  pericardial  eiFusion  to  be  differ- 
entiated ? 

An  effusion  of  fluid  into  the  pericardium  may  take  place  as 
part  of  a  general  dropsy.  It  presents  physical  phenomena 
indistinguishable  from  those  of  pericarditis  in  the  stage  of 
effusion,  though  without  the  febrile  symptoms,  and  the  friction- 
murmurs  of  the  first  and  third  stages.  Other  evidences  of 
general  dropsy,  such  as  edema,  pleural  and  peritoneal  effusions, 
and  symptoms  or  signs  of  the  causative  disease — nephritis,  for 
example — will  be  found  if  looked  for. 

Heart-Clot. 

What  are  the  symptoms  of  heart-clot  ? 

The  blood  may  coagulate  in  the  cavities  of  the  heart  in  the 
course  of  endocarditis,  of  diseases  in  which  the  coagulability  of 
the  blood  is  increased,  such  as  pneumonia,  and  when  from  any 
cause  the  action  of  the  heart  has  become  enfeebled.  Under  such 
circumstances  the  surface  of  the  body  becomes  cold  and  livid, 


DISEASES    OF   THE    31  ED  I  A  ST  I  N  U  M  .  141 

there  is  intense  dyspnea,  the  action  of  the  heart  becomes  rapid, 
feeble  and  irrej^ular,  a  faint  murmur  may  be  lieard  over  the 
organ  and  the  area  of  cardiac  percussion-dulness  is  increased. 
There  is  great  anxiety,  nausea,  vomiting,  nervous  excitement, 
dehrium,  venous  turgidity  and  attacks  of  syncope. 

Diseases  of  the  Mediastinum. 

What  are  the  most  common  disorders  of  the  mediastinum  ? 

There  may  be  simple  or  suppurative  lymijhadenitis,  new- 
growths  and  emphysema. 

What  are  the  general  clinical  features  of  mediastinal  disease  ? 
Apart  from  the  constitutional  symptoms  there  may  be  pain, 
dyspnea,  cough,  hoarseness,  distention  of  veins,  edema,  dys- 
phagia, variations  in  the  size  of  the  pupils,  with  protrusion  of 
the  sternum,  dulness  on  percussion,  enfeeblement  of  the  breath- 
sounds,  diminished  vocal  resonance  and  fremitus,  and  displace- 
ment of  the  heart.  Emphysema,  when  it  appears  externally, 
gives  rise  to  a  peculiar  doughy  swelling,  with  crackling  on  pal- 
pation. 

Thoracic  Aneurism. 

What  are  the  symptoms  of  thoracic  aneurism  ? 

The  symptoms  and  physical  signs  of  thoracic  aneurism  vary 
with  the  location  of  the  aneurism.  Aneurisms  of  the  aorta  are 
the  most  common.  The  frequency  of  aneurisms  of  the  aorta 
diminishes  with  the  distance  from  the  heart.  The  characteristic 
manifestations  of  an  aneurism  are  the  existence  in  the  course 
of  a  bloodvessel  of  a  pulsating  expansile  tumor^  attended  with  a 
thrill  and  bruit  and  diastolic  shock;  on  percussion  a  circum- 
scribed area  of  dulness  will  be  found  to  correspond  with  the  area 
of  expansile  pulsation,  over  which  a  thrill  can  be  perceived 
with  the  palpating  hand,  and  a  sj'stolic  bruit  can  be  heard  on 
auscultation.  Other  symptoms  depend  upon  the  compression 
of  adjacent  structures.  There  may  thus  be  pain,  a  peculiar 
metallic  cough,  with  or  without  expectoration  ;  dyspnea,  dA^s- 
phagia ;  irregularity  of  the  action  of  the  heart ;  venous  stagna- 


142  ESSENTIALS    OF    DIAGNOSIS. 

tion  and  edema ;  manifestations  of  derangement  of  tlic  cerebral 
circulation  ;  localized  sweating ;  dilatation  or  contraction  of  one 
pupil;  paralysis  of  one  or  both  vocal  bands ;  enfeeblement  of 
respiratory  murmur  over  certain  areas,  from  obstruction  of  a 
large  bronchus ;  inequality  of  the  radial  pulses  or  obliteration 
of  pulsation  in  peripheral  arteries;  tracheal  tugging;  neuralgic 
pain  and  erosion  of  bone.  Rupture  may  take  place,  externally 
or  into  an  adjacent  viscus,  with  gradual  oozing  or  fatal  hemor- 
rhage. Examination  with  the  fluoroscope  will  usually  reveal 
the  presence  of  an  abnormal  shadow,  which  may  be  seen  to 
contract  and  expand  with  the  pulsation  of  the  aneurism.  The 
shadow  will  be  more  definitely  located  by  skiagraphy. 

How  is  an  intra-thoracic  tumor  to  be  distinguished  from  an 
aortic  aneurism  ? 
An  aneurism  develops  only  in  the  course  of  a  bloodvessl ;  a 
tumor  of  any  other  sort  is  not  so  restricted.  The  former  presents 
pulsation,  expansion,  and  usually  thrill  and  bruit ;  the  latter 
may  rise  and  fall  if  seated  over  an  artery,  but  does  not  expand 
or  present  a  thrill  or  bruit.  The  sphygmographic  tracing  (taken 
in  loco)  of  a  solid  tumor  situated  above  a  normal  artery  is  that 
of  the  normal  artery  ;  the  curve  given  by  an  aneurism  is  abnor- 
mal and  often  characteristic.  Intra-thoracic  tumors  are  usually 
either  secondary  or  give  rise  to  metastases.  If  the  tumor  were 
a  gumma,  the  diagnosis  would  depend  upon  a  history  of  syphilis 
or  upon  other  manifestations  of  syphilis,  together  with  a  reces- 
sion of  the  symptoms  on  appropriate  treatment.  Tuberculosis 
of  the  mediastinal  glands  would  be  but  one  manifestation  of  a 
general  tuberculosis. 

How  is  an  abscess  of  the  mediastinum  to  be  distinguished  from 
an  aneurism  of  the  aorta  ? 
In  addition  to  the  features  that  distinguish  all  other  thoracic 
tumors  from  aneurism,  an  abscess  presents  fluctuation  if  acces- 
sible, rigors,  elevation  of  temperature,  and  sweating.  There  is  a 
history  of  traumatism  or  of  pyemia. 

How  is  incompetency  of  the  aortic  valve  to  be  distinguished 
from  an  aneurism  of  the  aorta  ? 

Incompetency   of   the    aortic   valve    may   be   attended   with 
marked  pulsation  in  the  course  of  the  aorta,  with  a  thrill  and 


ARTERIO-CAPILLARY    FIBROSIS.  143 

bruit,  but  the  evidences  of  tumor  and  the  consequences  of  com- 
pression are  wanting  ;  the  radial  i)ul.ses  are  of  the  Corrigan  or 
water-hammer  t3q3e,  but  are  equal ;  while  the  second  sound  of 
the  heart  at  the  base  is  accompanied  or  replaced  by  a  murmur 
transmitted  downwards  in  the  course  of  the  sternum. 

How  is  a  dilated  auricle  to  be  distinguished  from  an  aortic 
aneurism  ? 
An  enlarged  auricle  may  give  rise  to  pulsation  at  the  base  of 
the  heart,  but  not  to  the  compression-phenomena  of  an  aneur- 
ism, not  to  the  thrill  or  bruit,  beyond  the  sounds  generated  in 
the  heart  itself  as  a  result  of  the  lesion  that  has  led  to  the 
enlargement  of  the  auricle  :  usually  obstruction  at  the  mitral 
orifice  with  a  presystolic  murmur. 

How  are  a  thoracic  aneurism  and  pulsating*  pleurisy  to  be 
differentiated  ? 

While  left-sided  empj'ema  is  sometimes  attended  with  pulsa- 
tion transmitted  through  the  heart,  it  is  unattended  with  the 
auscultatory  signs  and  the  expansion  of  aneurism,  and  it  is, 
besides,  indicated  by  the  physical  signs  of  a  pleural  effusion. 

Arterio- Capillary  Fibrosis. 

What  is  arterio-capillary  fibrosis  ? 

Arterio-capillary  fibrosis  is  a  degenerative  process  of  the  walls 
of  the  smaller  bloodvessels,  due  to  the  long-continued  circulation 
in  the  blood  of  irritants,  such  as  alcohol,  lead,  the  poisons  of 
syphilis,  of  gout,  of  rheumatism,  and  of  infectious  diseases.  It 
may  be  a  result  also  of  constant  or  frequent  increase  in  arterial 
pressure  from  whatever  cause.  Sometimes  an  inherited  pre- 
disposition exists.  Vaso-motor  spasm  and  hyperplasia  of  the 
connective  tissue  of  the  arteries  and  of  the  intercellular  ele- 
ments of  parenchymatous  organs  take  place.  The  coats  of  the 
vessels  become  thickened  and  the  size  of  organs  becomes  in- 
creased. From  secondary  contraction  of  the  newly-formed 
fibrous  tissue,  the  lumen  of  the  arteries  becomes  narrowed 
and  the  organs  become  reduced  in  size.  The  circulation  is  cur- 
tailed and  nutritive  processes  are  interfered  with ;  atrophy  may 


144  ESSENTIALS    OF    DIAGNOSIS. 

result ;  thrombi  may  form  in  situ.  Sclerotic  vessels  are  prone 
to  rupture,  in  the  brain,  in  the  retina,  and  elsewhere.  It  has 
been  suggested  that  the  condition  is  really  one  of  hyperplasia 
of  the  muscular  layer  of  the  arteries — arterial  hypermyotrophy. 

What  are  the  symptoms  of  arterio-eapillary  fibrosis  ? 

The  diagnostic  S3aiiptoms  of  arterio-eapillary  fibrosis  or  arterio- 
sclerosis are  those  of  vascular  spasm,  impeded  circulation,  and 
impaired  nutrition  :  shortness  of  breath,  vertigo,  mental  impair- 
ment, nervous  derangement,  irregularity  of  cardiac  action, 
resistant  radial  arteries,  prominent,  tortuous  temporals,  in- 
creased arterial  tension.  Edema  may  be  present.  The  urine 
becomes  increased  in  quantity  and  may  contain  a  trace  of  albu- 
min and  an  occasional  tube-cast.  Numbness  and  coldness  of  the 
extremities  are  common.  The  nails  are  sometimes  bluish  from 
impeded  circulation.  The  knee-jerk  is  often  exaggerated.  Tran- 
sient local  palsies  sometimes  occur.  Angina  pectoris  and  pseudo- 
angina  are  not  uncommon.  The  action  of  the  heart  may  be 
arrhythmic  and  the  sounds  duplicated  ;  the  second  or  arterial 
sound  is  usually  accentuated.  An  hypertrophied  left  ventricle, 
without  valvular  disease  of  the  heart,  should  be  suggestive  of 
the  existence  of  vascular  disease.  Chronic  interstitial  nephritis 
is  a  frequent  result  of  arterio-eapillary  fibrosis,  or  of  the  same 
causes  that  give  rise  to  the  vascular  changes.  Cerebral  and 
retinal  thrombosis  or  hemorrhage  may  be  compUrations. 

Local  Syncope — Local  Asphyxia — Local  or  Sym- 
metrical Gangrene. 

What  are  the  symptoms  of  Raynaud's  disease? 

Raynaud's  disease  is  a  vaso-motor  neurosis  characterized  by 
pallor,  lividity  or  gangrene  of  peripheral  portions  of  the  body, 
as  fingers,  toes,  nose  and  ears,  especially  induced  by  cold,  and 
sometimes  attended  with  hemoglobinuria.  The  disorder  is  be- 
lieved to  be  dependent  upon  spasm  of  arterioles,  with  dilatation 
of  small  veins.  In  accordance  with  the  intensity  of  the  morbid 
process  and  the  clinical  manifestations  the  condition  is  desig- 
nated local  syncope^  local  asphyxia  or  local  gangrene.    The  affected 


ERYTHROMELALGIA.  145 

parts  may  be  the  seat  of  severe  pain.  When  gangrene  takes 
place  cicatrization  follows  as  a  rule.  In  rare  instances  exten- 
sive areas  are  involved,  sometimes  even  parts  of  the  trunk,  and 
death  ma}'  result. 

How  are  the  symptoms  of  Raynaud's  disease  and  those  resulting 
from  frost-bite  to  be  differentiated  ? 

The  appearances  presented  by  Raynaud's  disease  and  those 
presented  by  frost-bite  may  be  almost  indistinguishable.  Frost- 
bite is  not  likely,  however,  to  exhibit  the  symmetry  of  distribu- 
tion observed  in  cases  of  Raynaud's  disease.  The  symptoms  of 
frost-bite,  moreover,  usually  recede  when  cold  weather  departs, 
while  the  manifestations  of  Raynaud's  disease  persist,  though, 
perhaps,  also  aggravated  by  cold.  Raynaud's  disease  is  not 
necessarily  dependent  upon  severe  cold  as  a  cause  ;  while  frost- 
bite is  essentially  so  dependent. 


Erythromelalgia. 

What  is  erythromelalg-ia  ? 

Erythromelalgia  is  a  morbid  condition  characterized  by  pain 
and  redness  of  one  or  more  extremities,  aggravated  by  the 
dependent  position  and  by  heat,  and  attended  with  local  eleva- 
tion of  temperature.  It  is  thought  to  be  due  to  inflammation 
of  nerve-end  filaments.  Peripheral  nerves  have  been  found 
degenerated  and  peripheral  arteries  sclerotic.  The  condition 
has  been  observed  also  in  association  with  central  nervous 
disease. 

How  are  Raynaud's  disease  and  erythromelalg-ia  to  be  differ- 
entiated ? 

Raynaud's  disease  is  more  common  in  females,  erythromel- 
algia in  males.  In  the  former  the  affected  parts  become  white 
or  cyanotic  or  gangrenous  and  cold,  while  in  the  latter  they 
become  dusky-red  or  violaceous  and  hot.  Erythromelalgia  is 
by  far  the  more  jDainful  aff'ection  and  is  aggravated  by  heat  and 
the  dependent  position,  while  Raynaud's  disease  is  made  worse 
by  cold. 
10 


146  ESSENTIALS    OF    DIAGNOSIS. 

Angioneurotic  Edema. 

What  is  angioneurotic  edema  ? 

Angioneurotic  edema  is  a  vaso-motor  disorder  characterized  by 
the  appearance  suddenly  of  more  or  less  circumscribed  swellings 
in  one  or  other  portion  of  the  body,  with  equally  sudden  dis- 
appearance. The  attack  is  sometimes  attended  with  colicky 
pain  and  symptoms  of  gastro-intestinal  disturbance.  Involve- 
ment of  the  larynx  may  cause  death  by  asphyxia.  Some  cases 
exhibit  periodicity  of  recurrence.  The  predisposition  to  the 
affection  is  often  inherited. 


THE  RESPIRATORY  SYSTEM. 

How  are  affections  of  the  upper  air-passages  (nose,  pharynx, 
larynx  and  trachea)  to  be  diagnosticated  ? 

The  diagnosis  of  affections  of  the  upper  air-passages  is  based, 
in  part,  upon  the  symptoms  ;  but  the  only  certain  methods  are 
those  of  direct  insinction^  or  of  indirect  inspection  \>y  means  of  a 
suitable  mirror.  Tor  both  direct  and  indirect  inspection, 
proper  illumination  is  necessary.  When  direct  daylight  does 
not  suffice,  a  reflector  is  employed,  either  with  daylight  or  with 
artificial  light.  There  are  also  apparatus  for  direct  illumination 
by  artificial  light.  Palpation  with  probe  or  finger  is  sometimes 
additionally  necessary. 

It  is  sometimes  necessary  to  remove  from  the  line  of  vision, 
by  means  of  suitable  retractors,  certain  structures,  as  the  an- 
terior palatine  folds,  the  uvula,  soft  palate  or  epiglottis. 

By  translumination^  or  transmission  of  light  through  the  tis- 
sues, information  is  sometimes  gained  as  to  the  comparative 
density  of  structure. 

Direct  inspection  of  the  nasal  passages  by  means  of  a  specu- 
lum inserted  by  way  of  the  nostrils  is  called  anterior  rhinoscopy. 

Indirect  inspection  of  the  nasal  passages  by  means  of  a 
mirror  so  placed  in  the  pharynx,  behind  and  below  the  soft 
palate,  as  to  reflect  an  image  of  the  posterior  choanse  and 
neighboring    structures,    is    called   x:)Osterior  rhinoscopy.      The 


THE    RESPIRATORY    SYSTEM.  147 

vault  of  the  pharynx  and  the  mouths  of  the  Eustachian  tubes 
are  examined  by  the  methods  of  posterior  rhinoscopy. 

Direct  inspection  of  the  pharynx  is  termed  direct  jjharyngo- 
scopy.  To  carry  it  out,  only  light  to  illuminate  and  a  spatula 
to  depress  the  tongue  are  required.  Those  parts  of  the  pharynx 
inaccessible  to  direct  inspection  are  examined  by  means  of  a 
mirror  appropriately  placed  [indirect  pliaryngoscoijy). 

The  laryngeal  structures  are  rarely  accessible  to  direct  inspec- 
tion. Sometimes  a  part  of  the  epiglottis  may  be  seen,  and  in 
exceptional  instances  a  glimpse  of  the  supra-arytenoid  struc- 
tures has  been  obtained.  With  the  aid  of  a  special  tongue- 
depressor  (Kiastew's  autoscope),  however,  the  structures  may 
be  dragged  forward  and  the  vocal  bands  and  posterior  laryngeal 
wall  brought  into  view. 

Laryngoscopy  is  practised  by  means  of  a  mirror  so  placed  in 
the  pharynx,  with  the  uvula  lifted  out  of  the  way  upon  the 
back  of  the  mirror,  as  to  reflect  an  image  of  the  deeper  parts. 
In  favorable  cases,  the  interior  of  the  trachea,  to  its  bifurcation, 
may  be  seen.  When  the  patient  phonates,  the  superior  face  of 
the  vocal  bands  and  the  structures  above  are  reflected.  When 
the  patient  inspires  deeply,  the  internal  face  of  the  vocal  bands 
and  the  structures  below  are  additionally  revealed.  One 
endeavors  to  observe  the  contour,  the  color  and  the  motility  of 
the  various  parts,  and  to  determine  the  presence  or  absence  of 
secretion,  ulceration,  cicatrices,  abnormal  growths  or  foreign 
bodies. 

To  what  conditions  may  diificulty  of  nasal  respiration  be  due  ? 

Difficulty  of  nasal  respiration  may  be  dependent  upon  enlarge- 
ment, engorgement  or  distortion  of  the  septum  or  of  the  turbi- 
nate bodies,  upon  the  presence  of  foreign  bodies,  or  of  polj'pi 
or  other  neoplasms,  or,  especially  in  children,  upon  overgrowth 
of  the  glands  of  the  vault  of  the  pharynx  (adenoid  vegetations). 
The  diagnosis  can  be  made  only  by  rhinoscopy,  anterior  and 
posterior,  sometimes  in  conjunction  with  palpation. 

What  symptoms  other  than  those  directly  referable  to  the  nose 
may  arise  from  the  conditions  that  occasion  dif5.culty  in 
nasal  respiration  ? 
In  addition  to  the  local  symptoms,  the  conditions  that  occa- 


148  ESSENTIALS     OF     DIAGNOSIS. 

sion  difficulty  of  nasal  respiration  may  be  attended  by  anemia 
from  deficient  oxygenation,  together  with  persistent  cough,  facial 
tic,  headache,  asthmatoid  seizures,  epileptiform  convulsions, 
chorea,  exopthalmic  goiter,  or  various  other  reflex  disturbances. 
The  diagnositi  is  to  be  based  upon  a  careful  study  of  all  of  the 
phenomena  and  conditions,  general  and  local. 

What  is  a  frequent,  unsuspected  cause  of  epistaxis? 

An  ulceration  or  erosion  of  the  mucous  membrane  of  the  nasal 
septum,  usually  situated  near  the  anterior  inferior  angle  of  the 
triangular  cartilage,  is  a  not  uncommon  cause  of  epistaxis. 
Malignant  growth,  especially  sarcoma,  which  may  involve  the 
frontal  sinuses  and  even  be  hidden  from  rhinoscopy  is  another 
condition  worthy  of  mention.  The  bleeding  may  be  insignifi- 
cant in  quantity,  and  might  easily  be  considered  of  little 
moment. 

Coryza — Acute  Nasal  Catarrh. 

What  is  coryza? 

Coryza  or  acute  nasal  catarrh  is  a  superficial  inflammation  of 
the  nasal  mucous  membrane,  attended  by  sneezing  and  a  pro- 
fuse watery  discharge  from  the  nostrils.  There  is  usually  head- 
ache and  sometimes  more  or  less  fever.  The  swollen  membrane 
and  more  especially  the  engorged  turbinate  bodies  impede  res- 
piration and  modify  articulation.  In  the  course  of  a  few  days, 
the  discharge  becomes  more  viscid,  often  muco-purulcnt.  Usu- 
ally the  attack  subsides  completely  in  a  week.  Conjunctivitis, 
pharyngitis,  laryngitis,  bronchitis  and  otitis  media  are  among 
the  complications  and  sequelm  sometimes  manifested. 

How  is  coryza  to  be  differentiated  from  influenza? 

Some  authorities  refuse  to  make  a  distinction  between  coryza 
and  influenza.  Coryza,  with  conjunctivitis  or  bronchitis,  is 
sometimes  epidemic.  From  fully-developed  influenza,  simple 
coryza,  whether  due  to  cold,  to  non-specific  irritation  or  to  in- 
fection, differs  by  the  absence  of  the  constitutional  symptoms 
and  of  the  profound  depression  characterizing  the  former  disease. 
Characteristic  bacilli  are  present  in  the  secretions  from  a  case 
of  influenza, 


HAY-FEVER.  149 


Hay-Fever. 

What  is  hay-fever? 

Hay-fever,  hdij-asthma,  rag-weed  fever  ^  autumnal  catarrh,  June 
cold.,  rose-cold,  idiosynaxitic  coryza,  periodic  vasomotor  coryza,  are 
names  applied  to  a  group  of  symptoms  developed  in  susceptible 
individuals  as  the  effect  of  special  irritants  upon  the  mucous 
membranes  of  the  eyes  and  air-passages,  more  especially  of  the 
nose.  The  mauifesiations  vary  much  in  severity  and  in  con- 
stancy in  difterent  individuals,  and  in  the  same  individual  at 
different  times,  and  comprise  conjunctivitis,  coryza,  pharyngitis, 
laryngitis,  bronchitis,  asthma  and  gastric,  enteric  and  renal 
crises.  There  is  commonly  intolerable  itching  of  the  eyelids 
and  of  the  palate.  Fever  is  not  common  ;  but  when  it  occurs, 
it  is  irregular. 

In  some  individuals  the  syndrome  occurs  when  any  irritating 
substance  gains  entrance  to  the  nasal  passages.  In  others  the 
powder  of  certain  drugs,  such  as  ipecacuanha,  or  the  pollen  of 
certain  plants,  such  as  grasses,  rag-weed,  roses,  is  the  exciting 
cause.  The  ijredisijosing  cause  is  usually  a  neurotic  constitution, 
perhaps  induced  by  excessive  mental  exertion  or  by  undue  in- 
dulgences; sometimes  the  presence  of  nasal  abnormities  aggra- 
vates the  sj^mptoms. 

In  those  in  whom  the  attacks  depend  on  special  pollens,  the 
manifestations  necessarily  vecur  periodiccdly.  In  ^orth  America 
the  rag-weed  is  the  most  common  provocative  agent,  and  with 
most  sufferers  the  attacks  begin  about  the  middle  of  August,  and 
last  until  the  cause  has  disappeared.  June-colds  are  dependent 
on  hay  and  roses. 

How  is  hay-fever  to  be  distinguished  from  simple  coryza? 

The  distinguishing  features  of  hay-fever  are  the  invariability 
of  its  causation,  and  the  severity  and  association  of  its 
symptoms  ;  together  with  the  rapid  disappearance  of  symptoms 
on  removal  to  a  locality  (usually  the  mountains  or  the  seashore) 
where  the  provocative  agency  is  not  present. 


150  ESSENTIALS    OF    DIAGNOSIS. 

Acute    Laryngitis. 

What  are  the  symptoms  of  acute  laryngitis? 

Acute  laryngitis  usually  results  from  exposure  to  cold,  or  from 
the  inhalation  of  irritating  fumes.  It  occurs  deuteropathically 
in  the  course  of  many  inflammatory  and  infectious  diseases, 
whether  general  or  of  the  respiratory  or  digestive  organs.  With 
great  variations  in  the  degree  of  severity,  it  manifests  itself  by 
laryngeal  irritation,  hoarseness  or  painful  aphonia,  painful  deglu- 
tition, dyspnea  and  slight  hawking  cough,  with  mucous  expec- 
toration. 

There  may  also  be  slight  elevation  of  temperature. 

Laryngoscopically,  the  laryngeal  structures  will  be  seen  to  be 
more  or  less  reddened  and  swollen.  If  edema  occur,  the  breath- 
ing will  be  labored  and  stridulous,  swallowing  excessively  pain- 
ful and  finally  impossible,  and,  as  a  result  of  the  impediment 
to  respiration,  cyanosis  may  develop.  Laryngoscopy  or  palpa- 
tion will  reveal  the  cause. 

How  is  laryns^itis  to  be  distinguished  from  pharyngitis? 

The  only  reliable  method  of  discrimination  is  by  inspection, 
both  directly  and  by  means  of  the  mirror,  as  symptoms  are  very 
likely  to  be  misleading,  and  the  two  affections  not  infrequently 
coexist. 

In  pharyngitis  the  alteration  in  voice— aphonia  or  hoarse- 
ness, of  laryngitis  is  wanting.  The  difficulty  and  pain  of  swal- 
lowing are  likely  to  be  the  less  in  laryngitis,  and  inspection  will 
reveal  the  seat  of  the  inflammation. 

How  does  parotiditis  differ  from  laryngitis  ? 

In  parotiditis  the  voice  remains  unaffected.  In  laryngitis 
there  is  no  swelling  about  the  face. 

How  does  tonsillitis  differ  from  laryngitis  ? 

Inspection  discloses  the  swelling  of  the  tonsils  and  the  absence 
of  involvement  of  the  larynx. 

In  tonsillitis  the  voice  may  be  nasal,  but  it  is  not  hoarse  or 
lost ;  cough  and  expectoration  are  absent,  while  the  difficulty  of 
breathing  may  be  great. 


EDEMA    OF    THE    LARYNX.  151 

The  difficulty  and  pain  of  swallowing  are  greater  in  tonsillitis 
than  in  laryngitis. 

How  does  hysterical  aphonia  differ  from  acute  laryngitis  ? 

Hysterical  aphonia,  as  a  rule,  sets  in  more  or  less  suddenly  ; 
often  in  association  with  emotional  disturbance,  in  a  person, 
usually  a  female,  presenting  other  manifestations  of  hysteria  ; 
and  is  unattended  with  pain,  difficulty  of  breathing  or  elevation 
of  temperature.  Laryngoscopic  examination  will  reveal  the 
motor  impairment  of  the  vocal  bands,  and  the  non-existence  of 
an  inflammatory  process.  Recovery  may  take  place  as  suddenly 
as  did  the  onset.     The  attack  is  likely  to  be  repeated. 

Edema  of  the  Larynx. 

What  are  the  symptoms  of  acute  edema  of  the  larynx  ? 

Acute  edema  of  the  lavyno:  may  occur  so  insidiously  as  to  pro- 
duce death  without  giving  rise  to  appreciable  symptoms,  or 
the  symptoms  may  be  sudden  and  overwhelming. 

When  edema  of  the  larynx  occurs  in  the  course  of  other 
affections,  or  as  a  sequel,  there  may  be  the  usual  prodromes  of 
inflammatory  fever,  but  as  a  rule  the  onset  is  sudden,  and  the 
severity  of  the  attack  rapidly  increases.  There  are  local  ten- 
derness, dryness  and  heat  in  the  throat,  with  a  sensation  as 
of  the  presence  of  a  foreign  body  ;  more  or  less  ineffectual 
cough  ;  muffling  or  extinction  of  voice  ;  difficulty  of  swallowing  ; 
difficulty  of  inspiration,  with  harsh  stridor,  occurring  in  par- 
oxysms that  increase  in  frequency  and  severity,  and  unless  re- 
lief be  afforded,  result  in  expiratory  difficulty  and  apnea. 
Bespiration  is  hurried  and  spasmodic  ;  the  jji/Jse  is  small,  fre- 
quent and  irregular ;  the  temxjerature  is  elevated  ;  the  eyes  are 
prominent ;  the  face  is  flushed  and  anxious,  finally  cyanotic. 

When  dependent  upon  acute  disease,  the  suflbcative  attacks 
will  be  abrupt  and  violent,  and  will  recur  at  intervals  of  a  few 
hours. 

"When  dependent  upon  chronic  disease,  the  paroxysms  may 
pass  ofl',  to  recur  irregularly,  at  progressively  shorter  intervals. 
Fever  is  absent,  unless  the  underlying  disease  itself  be  febrile. 


152  ESSENTIALS    OF    DIAGNOSIS. 

Simple  inspection  of  the  pharynx  may  reveal  the  swollen 
epiglottis  projecting  up  behind  the  base  of  tlie  tongue.  PaZpa- 
tiwi  with  the  finger  may  detect  a  soft,  elastic,  bladder-like  swell- 
ing of  the  epiglottis,  or  of  the  ary-epiglottic  folds  ;  but  unless 
cautiously  practised  it  may  induce  a  paroxysm  of  suffocation 
from  the  additional  obstacle  or  irritation.  Laryngosco^nc  ex- 
amination at  once  reveals  the  cause  of  the  symptoms. 

What  are  the  symptoms  of  chronic  edema  of  the  larynx  ? 

Chronic  edema  of  the  larynx  may  be  due  to  laryngeal  disease, 
or  to  the  usual  causes  of  effusions.  It  gives  rise  eventually  to 
progressive  difficulty  of  breathing,  paroxysmally  aggravated, 
with  perhaps  some  impairment  of  voice,  and  pain  or  difficulty 
in  swallowing.  The  diagnosis  is  only  to  be  made  by  laryngo- 
scopy, in  default  of  which  palpation  may  perhaps  be  of  service. 

How  is  chronic  edema  of  the  larynx  to  be  distinguished  from 
asthma  ? 

Principally  by  laryngoscopic  examination.  The  paroxysms 
may  exactly  simulate  asthmatic  attacks.  Suffocative  parox- 
ysms, due  to  laryngeal  neoplasm,  may  likewise  be  mistaken  for 
asthma  if  laryngoscopic  examination  be  not  made.  Before  the 
days  of  laryngoscopy  many  cases  of  sudden  death  were  found  to 
be  due  to  laryngeal  neoplasm. 

Acute  Tuberculous  Laryngitis, 

What  are  the  characteristics  of  acute  tuberculous  laryngitis  ? 

Acute  tiiberculous  laryngitis  is  characterized  by  the  constitutional 
symptoms  of  acute  miliary  tuberculosis,  and  locally  by  great 
pain  in  swallowing,  by  cough,  dysphonia  or  hoarseness,  and 
sometimes  pain  in  respiration.  Laryngoscopic  inspection  reveals 
peculiar  thickenings  of  the  epiglottis  and  other  larj-ngeal  struc- 
tures, which  are  quickly  followed  b}'^  ulceration  ;  or  there  may 
be  ulceration  from  the  first.  Tubercle-bacilli  are  sometimes  to 
be  detected  in  the  secretions  or  in  the  debris  of  ulcers. 

Laryngeal  manifestations  are  sometimes  observed  before  evi- 
dences of  pulmonary  tuberculosis  can  be  detected  ;  but  the  lat- 
ter, sooner  or  later,  become  manifest.     A  somewhat  rapid  fatal 


LARYNGEAL   VERTIGO.  153 

termination  is  the  rule,  but  recognized   instances  of  recovery 
are  multiplying. 

Laryngismus  Stridulus. 

What  is  laryngismus  stridulus  ? 

Laryngismus  stridulus  is  a  spasmodic  affection  characterized 
b}'  contraction  of  the  constrictor  muscles  of  the  larynx,  giving 
rise  to  d3^spnea,  inspiratory  stridor  and  a  ringing,  croupy  cough. 
It  occurs  most  frequently  in  rachitic  children.  The  attacks  are 
paroxysmal  and  usually  nocturnal.  The  child  may  be  awakened 
from  sleep  with  a  sense  of  suffocation  and  an  appearance  of 
lividity.  The  paroxysm  lasts  for  a  few  minutes  and  terminates 
with  a  deep  inspiration,  attended  with  a  crowing  sound.  Occa- 
sionally death  results  in  the  paroxysm  ;  perhaps,  from  incarce- 
ration of  the  epiglottis. 

How  does  laryngismus  stridulus  differ  from  asthma  ? 

Laryngismus  stridulus  is  a  disease  of  childhood  ;  asthma  is 
rare  in  children. 

Rickets  predisposes  to  laryngismus  stridulus  ;  asthma  may  be 
apparently  idiopathic,  or  some  recognized  irritation,  direct  or 
reflex,  may  be  discoverable.  The  wheezing  and  rales  of  asthma 
differ  from  the  cough  and  stridor  of  laryngismus. 

The  asthmatic  paroxysm  terminates  in  abundant  expectora- 
tion ;  laryngismus  stridulus  subsides  without  critical  pheno- 
menon. 

Laryngeal  Vertigo. 

What  is  laryngeal  vertigo  ? 

The  name  laryngeal  vertigo  is  applied  to  a  group  of  symptoms 
of  rare  occurrence  that  may  appear  in  connection  with  recog- 
nized nervous  diseases,  as  posterior  spinal  sclerosis  or  epilepsy, 
or  without  obvious  explanation.  The  symptoms  are  not  always 
the  same,  but  the  essential  elements  in  association  are  pain 
or  spasm  of  the  larynx,  vertigo  and  perhaps  syncope.  The  oc- 
currence of  laryngeal  vertigo  should  lead  to  careful  search  for 
symptoms  or  signs  of  the  causative  disorder. 


154  ESSENTIALS    OF    DIAGNOSIS 


Catarrhal  Croup— Spasmodic  Croup. 

What  is  catarrhal  or  spasmodic  croup? 

Catarrhal  or  spasmodic  croup  is  essentially  a  catarrhal  laryn- 
gitis, associated  with  a  tendency  to  spasm  of  the  constrictor 
muscles  of  the  larynx,  causing  paroxysms  of  suffocation.  It  is 
almost  exclusively  a  disease  of  children.  It  may  follow  exposure, 
ma}^  be  simultaneous  with  the  prevalence  of  epidemics  of  influ- 
enza, of  measles  or  of  scarlatina.  It  may  begin  insidiously  with 
slight  hoarseness,  or  suddenly,  with  chill.  It  usually  attracts 
attention  at  first  toward  evening  ;  the  voice  will  be  hoarse,  with 
a  slight  cough.  In  the  middle  of  the  night,  the  child  will  sud- 
denly awaken,  with  crying  and  paroxysms  of  suffocation,  and 
with  a  peculiar,  ringing,  metallic  cough,  which  is  termed  croupy. 
There  is  slight  elevation  of  temperature.  The  spasm  may 
quickly  pass  away,  or  it  may  be  repeated  several  times  during 
the  night  and  for  three  or  four  successive  nights,  the  symptoms 
of  ordinary  laryngeal  or  laryngo-bronchial  catarrh  being  mani- 
fested during  the  day.  Recovery  may  take  place,  or  high  fever 
may  set  in,  with  a  firm,  bounding  pulse,  flushing  of  the  cheek, 
abnormal  brilliance  of  the  eye,  and  development  of  the  ob- 
structive symptoms  of  pseudo-membranous  laryngitis. 

How  does  catarrhal  croup  differ  from  laryngismus  stridulus  ? 

Laryngismus  stridulus  is  a  disorder  of  repeated  occurrence, 
and  comparatively  chronic  duration,  occurring  in  rachitic  chil- 
dren, and  not  associated  with  fever,  cough  or  other  symptom 
of  inflammation.  Spasmodic  croup  begins  acutely,  is  of  short 
duration,  attacks  healthy  as  well  as  rachitic  children,  and  is 
associated  with  slight  fever,  cough  and  symptoms  of  catarrhal 
inflammation. 

How  are  croup  and  edema  of  the  larynx  to  be  distinguished  ? 

Apart  from  the  revelations  of  laryngoscopy,  croup  is  a  disease 
of  childhood  principally — edema  usually  occurs  in  adults.  In 
febrile  cases  the  history  of  exposure  to  irritating  fumes,  or  of 
other  exciting  cause  of  acute  edema,  the  pain  in  swallowing, 
and  the  local  tenderness  ;  in  other  cases  the  absence  of  fever, 


MEMBRANOUS    CROUP.  155 

and  the  knowledge  of  the  existence  of  causative  conditions ; 
together  with  the  absence  of  the  croupal  cough,  and  the  purely 
inspiratory  character  of  the  stridor,  are  additional  discrimina- 
tive features  of  edema. 

Membranous  Croup. 

What  are  the  symptoms  of  memhranous  croup  ? 

Membranous  croup  or  pseudo-memhranous  laryngitis^  whether  an 
idiopathic  disease  or  due  to  the  extension  or  original  formation 
of  diphtheritic  membrane  in  the  larynx  and  trachea,  is  mani- 
fested by  symptoms  of  mechanical  and  spasmodic  or  paralytic 
obstruction  of  the  larynx  and  trachea,  associated  with  more  or 
less  fever  and  the  constitutional  symptoms  of  diphtheria,  if  that 
disease  be  present.  In  some  instances,  the  palate,  tonsils  and 
pharynx  are  involved  in  simple,  exudative  or  diphtheritic  in- 
flammation. In  severe  cases,  the  process  extends  into  the 
bronchi,  and  in  some  cases  there  is  pneumonitis.  There  is  a 
peculiar  ringing  cough,  which  gradually  becomes  muffled,  with 
progressive  muffling  or  extinction  of  the  voice  ;  and  great  diffl- 
culty  in  breathing,  intensified  in  paroxysms,  w^hich  may  pro- 
gress to  suffocation.  Evidences  of  the  severity  of  the  obstruc- 
tion are  the  recession  upon  inspiration  of  the  soft  tissues  above 
and  below  the  sternum  and  the  use  by  the  child  of  the 
auxiliary  muscles  of  respiration,  in  its  efforts  to  obtain  breath. 
There  is  extreme  restlessness  and  agitation,  with  paroxysmal 
exacerbations,  attended  by  protrusion  of  the  eyeballs,  distention 
of  the  nostrils,  tlushing  of  the  cheek,  grasping  at  supports. 

Sometimes  a  child  will  sit  up  straight  in  bed  and  clutch  at  its 
neck,  as  if  trying  to  pull  away  some  obstruction. 

Suffocative  paroxysms,  being  partly  spasmodic,  are  sometimes 
relaxed  by  the  effects  of  the  resulting  carbonic  acid  poisoning, 
and  with  the  production  of  cyanosis  there  comes  a  deep  sighing 
expiration,  followed  by  a  deep  inspiration,  and  a  period  of  com- 
parative quiet. 

Flakes  of  membrane  or  even  membranous  casts  of  the  trachea 
and  bronchi  ma}'  be  expectorated.  The  duration  may  be  short, 
from  twenty-four  to  forty-eiglit  hours  ;  it  may  be  prolonged  to 


156  ESSENTIALS    OF    DIAGNOSIS. 

two  or  three  weeks  ;  usually,  however,  asphyxia  or  recovery  oc- 
curs in  from  five  to  eight  days.    Convulsions  often  precede  death. 

How  are  membranous  croup  and  retropharyngeal  abscess  to  be 
distinguished  ? 
Retropharyngeal  abscess  may  be  detected  by  inspection  and 
palpation.  The  evidence  of  tuberculosis  or  syphilis,  the  history 
of  previous  infectious  disease,  may  be  suggestive  of  abscess.  The 
voice  is  toneless  but  distinct  in  croup  ;  in  abscess  it  is  nasal  and 
indistinct.  In  abscess  there  are  pain  and  difficulty  in  swallowing  ; 
these  symptoms  are  absent  from  croup.  In  abscess  there  is  stiff- 
ness of  the  neck,  with  tumefaction  and  pain  on  pressure  exter- 
nally ;  this  is  not  the  case  in  croup.  In  croup  there  is  a  pe- 
culiar cough  and  sometimes  expectoration  of  false  membrane  ; 
these  are  not  present  in  abscess. 

How  do  membranous  croup  and  catarrhal  croup  differ  ? 

In  catarrhal  croup  fever  and  constitutional  symptoms  are 
slight.  In  membranous  croup,  fever  is  severe  ;  and  in  diph- 
theria, toxemic  symptoms  are  evident. 

In  catarrhal  croup  the  obstruction  to  breathing  is  purely  spas- 
modic, and  disappears  with  relaxation  of  the  spasm. 

In  membranous  croup  there  is  mechanical  obstruction,  con- 
tinuing when  the  spasm  has  passed. 

In  catarrhal  croup  the  voice  remains  clear,  or  at  most  becomes 
hoarse  ;  the  cough  preserves  its  ringing,  "  croupal"  character. 
In  membranous  croup  voice  and  cough  become  toneless. 

In  membranous  croup  shreds  of  membrane  or  casts  may  be 
expectorated,  and  diphtheritic  membrane  is  sometimes  visible 
in  the  pharynx.  Laryngoscopic  inspection,  when  possible,  will 
settle  the  diagnosis. 

How  is  obstruction  of  the  larynx,  trachea  or  a  bronchus  by  a 
foreign  body  to  be  distinguished  from  croup  ? 
In  the  absence  of  the  history,  which  would  at  once  prevent 
error,  the  lack  of  fever  and  its  concomitants,  the  absence  of 
the  peculiar  cough,  the  variation  in  the  symptoms,  and  finally 
laryngoscopic  examination  or  the  evidences  of  bronchial  obstruc- 
tion discovered  on  auscultation  and  percussion,  permit  the  diag- 
nosis of  foreign  body  to  be  made. 


WHOOPING-COUGH  —  PERTUSSIS.  157 

Whooping-Cough — Pertussis. 

What  are  the  symptoms  of  whooping-cough  ? 

Pertus.'iis,  or  whooplny-coug/i^  is  a  contagious  disease  of  child- 
hood, attended  with  catarrhal  symptoms,  to  whicli  is  added  a 
peculiar  cough,  occurring  in  paroxysms  and  attended  with  a 
characteristic  whoop.  For  several  days  there  is  coryza,  accom- 
panied with  an  acrid  discharge,  conjunctivitis,  laryngitis  and 
bronchitis.  Tlie  cough  then  becomes  paroxysmally  explosive, 
a  series  of  expiratory  efforts  being  followed  by  a  peculiar,  ring- 
ing, inspiratory  whoop.  During  these  attacks  the  child  may 
become  livid  and  appear  as  if  about  to  suffocate  ;  sometimes 
vomiting  is  induced.  The  violence  of  the  cough  may  cause  ul- 
ceration of  the  under  surface  of  the  tongue  on  either  side  of  the 
frenum ;  or  there  may  be  hemoptysis  or  epistaxis.  Emphy- 
sema, interstitial  or  vesicular,  may  be  induced.  The  parox- 
ysips  are  repeated  w^ith  variable  frequency.  The  number  of 
colorless  blood-corpuscles,  especially  the  lymphocytes,  is  in- 
creased. The  disease  may  last  many  weeks,  the  severity  and 
number  of  attacks  progressively  diminishing.  It  may  be  com- 
plicated by  catarrhal  pneumonia,  which  sometimes  proves  fatal. 
Bronchitis  may  long  persist  as  a  sequel.  The  period  of  incuba- 
tion is  from  seven  to  ten  days.  The  disease  is  supposed  to  be 
dependent  upon  a  small  bacillus  with  rounded  extremities. 

What  are  points  of  discrimination  between  membranous  croup 
and  whooping-cough  ? 

In  whooping-cough  there  is  little  or  no  fever,  no  continuous 
dyspnea,  no  alteration  of  voice,  and  the  child  is  usually  up  and 
about,  unless  there  is  pulmonary  complication.  In  croup  there 
is  not  the  characteristic  whoop. 

What  are  the  differential  features  of  laryngismus  stridulus  and 
whooping-cough  ? 

Laryngismus  stridulus  is  a  paroxysmal  neurosis,  most  com- 
mon in  rickety  children  ;  whooping-cough  is  a  contagious  dis- 
ease that  attacks  all  children  alike. 

The  cough  of  laryngismus  stridulus  is  croupy  ;  that  of  whoop- 
ing-cough occurs  as  a  series  of  explosive  expiratory  sounds,  fol- 


158  ESSENTIALS    OF    DIAGNOSIS. 

lowed  by  a  distinctive  inspiratory  whoop.  During  the  intervals 
of  freedom,  whooping-cough  presents  the  symptoms  of  bron- 
chitis ;  laryngismus  stridulus  does  not. 

How  does  tuberculosis  of  the  bronchial  glands  differ  from 
whooping-cough  ? 

Whooping-cough  is  a  self-limited  disease  ;  tuberculosis  is 
not.  Grave  constitutional  symptoms  attend  the  latter ;  re- 
covery from  whooping-cough  is  comparatively  rapid.  While 
the  cough  induced  by  tuberculosis  of  the  bronchial  glands  is 
ringing,  it  does  not  possess  the  peculiar  character  of  the  cough 
of  pertussis.  Cases  of  whooping-cough  do  not  occur  isolated. 
By  pressure  on  adjacent  structures,  enlarged  bronchial  glands 
may  occasion  dyspnea,  cough  and  cyanosis,  and  edema  of  the 
face  and  neck. 

Chronic  Laryngitis. 

What  are  the  symptoms  of  chronic  laryngitis  ? 

Chronic  laryngitis  may  be  a  result  of  repeated  attacks  of  acute 
laryngitis  ;  it  may  depend  on  nasal  disease,  gastric  catarrh, 
dilated  heart,  constipation,  or  kidney  disease,  or  other  near  or 
remote  affection.  It  is  common  in  those  who  use  their  voices 
improperly  or  immoderately,  and  in  those  who  smoke  to  excess. 
It  is  characterized  by  hoarseness,  persistent,  irritable  cough 
and  discomfort  in  phonation  and  deglutition.  Laryngoscopically 
the  structures  within  the  larynx  are  seen  to  be  thickened,  con- 
gested, covered  by  tough  secretion  ;  the  vocal  bands  have  lost 
their  pearly,  glistening  appearance,  and  their  motility  may  be 
impaired.  In  many  cases  chronic  laryngitis  is  of  tuberculous 
or  of  syphilitic  origin.  In  such  cases  there  may  be  character- 
istic ulceration,  and  in  the  case  of  tuberculosis,  tumefaction  of 
the  epiglottis  and  aryteno-epiglottic  folds ;  vegetations  in  the 
meso-arytenoid  fold  are  quite  common. 

How  is  chronic  laryngitis  to  be  distinguished  from  laryngeal 
neoplasms  ? 

The  only  safe  method  of  diagnosis  is  by  means  of  laryngo- 
scopy, and  its  neglect  is  criminal. 


PHYSICAL    DIAGNOSIS.  159 


Chronic  Tuberculosis  of  the  Larynx. 

What  are  the  characteristics  of  chronic  tuberculosis  of  the 
larynx  ? 

In  case  of  chronic  tuberculosis  of  the  larynx  the  subjective  and 
objective  symptoms  may  be  simply  those  of  ordinary  chronic 
laryngitis,  or  there  may  be  characteristic  tumefactions,  ulcera- 
tions or  vegetations  in  the  larynx,  or  all  combined  ;  with  more 
or  less  pain  and  difficulty  in  swallowing  and  in  respiration,  and 
alteration  of  the  voice.  The  signs  of  pulmonary  tuberculosis 
are  usually  well  advanced.  Cases  of  recovery  from  the  local 
disease  in  the  larynx,  or  of  its  prolonged  abeyance,  are  not  rare. 

How  are  paralyses,  ulcerations,  abscess,  stricture  and  other 
conditions  affecting  the  larynx  and  trachea,  and  giving 
rise  to  alterations  in  voice  and  difficulty  in  respiration, 
to  be  diagnosticated  ? 

The  only  reliable  method  is  laryngoscopy. 


PHYSICAL  DIAGNOSIS. 

What  are  the  methods  of  physical  exploration  ? 

In  a  p%sicaZ  exploration^  systematically  conducted,  five 
means  of  investigation  are  employed  :  inspjection^  mensuration^ 
yalpati(n\  percussion  and  auscultation. 

What  does  physical  exploration  teach  ? 

By  physical  exploration  information  is  gained  of  physical  or 
mechanical  conditions,  so  far  as  these  may  influence  the  size,  con- 
tour, movement,  temperature,  density,  elasticit}^  and  acoustic 
relations  of  the  structures  examined.  The  nature  of  patho- 
logic conditions  cannot  be  directly  determined  from  physical 
signs,  but  is  to  be  inferred  from  the  latter  in  association  with 
all  other  phenomena  in  a  given  case. 

What  is  to  be  learned  by  inspection  ? 

By  inspection  the  general  appearance  of  an  individual  is 
noted — the  height,  the  apparent  relative  nutrition,  the  color, 


160  ESSENTIALS    OF    DIAGNOSIS. 

the  configuration,  the  movement,  the  state  of  the  pupils,  the 
expression. 

Examining  the  chest  more  especially,  its  symmetry  or  asym- 
metry, its  fulness  or  retraction  ;  the  frequency  and  character 
of  the  respiratory  movements  ;  the  extent  of  the  respiratory 
excursion  ;  the  situation,  extent  and  vigor  of  the  cardiac  im- 
pulse are  observed,  and  abnormal  manifestations  are  looked  for. 

The  chest  is  distended  symmetrically  in  emphysema  and 
usually  in  case  of  hydrothorax  ;  pleural  effusions  and  pneumo- 
thorax commonly  occasion  unilateral  bulging. 

The  chest  is  retracted  when  the  parietal  and  visceral  pleurae 
are  adherent,  and  when  the  lung  is  shrunken,  as  in  interstitial 
pneumonitis.  The  retraction  is  well  marked  after  some  forms 
of  operative  treatment  of  empyema,  and  when  the  lung  is  col- 
lapsed from  any  cause. 

A  healthy  adult  breathes  from  eighteen  to  twent}^  times  in 
the  minute.  The  normal  respiratory  excursion  is  curtailed  and 
the  frequency  of  respiratory  action  is  accelerated  by  almost  all 
diseases  of  the  lung  and  pleura  and  also  in  case  of  peritonitis. 
The  respiratory  frequency  is  also  accelerated  when  the  pulse 
is  quickened,  as  in  febrile  conditions.  In  case  of  pleurisy,  the 
patient  lies  on  the  affected  side,  so  as  to  reduce  to  a  minimum 
functional  movement  of  that  side.  Rapidity  of  breathing  may 
be  hysterical.  Women  breathe  mostly  with  the  upper  portion 
of  the  chest ;  men  with  the  lower. 

What  is  to  be  learned  by  mensuration? 

Mensuration  determines  with  precision  what  inspection  does 
approximately  :  the  size,  configuration,  symmetry  or  asym- 
metry and  respiratory  excursion  of  the  chest. 

What  is  to  be  learned  by  palpation  ? 

By  touch  or  palxjation  one  distinguishes  elasticity  from  rigidity 
and  resistance,  investigates  the  existence  of  pain  or  tenderness, 
of  edema,  of  moisture  or  dryness,  of  heat  or  cold.  When  the 
palm  of  the  hand  is  applied  to  the  chest  of  a  speaking  person  a 
diffuse,  vibratory  sensation  is  perceived,  usually  slightly  greater 
in  intensity  on  the  right  side  than  on  the  left.  This  is  known 
as  the  vocal  or  tactile  fremitus. 


PHYSICAL    DIAGNOSIS.  161 

It  is  increased  in  conditions  of  condensation  of  the  lung,  and 
diminished  or  lost  in  the  presence  of  thickening  and  adhesion 
of  the  surfaces  of  the  pleura  and  of  collections  of  fluid  in  the 
pleural  cavity.  Variations  in  vocal  fremitus  correspond  pretty 
closely  with  variations  in  vocal  resonance.  Sometimes  a  pleu- 
retic  friction-rub  can  be  felt. 

How  is  percussion  performed? 

Pcrcussioii  may  be  immediate  or  mediate.  In  the  former  a 
sharp  blow  is  struck  with  the  tips  of  the  fingers  bunched  together, 
or  with  the  palmar  surface  of  the  extended  fingers. 

Mediate  percussion  is  performed  by  means  of  a  thin,  flat  plate 
of  ivory  or  of  hard  rubber  (called  a  pleximeter),  applied  over  the 
part  to  be  examined,  and  a  small  rubber-tipped  hammer  (called 
a  plexor). 

For  many  purposes  it  is  preferable  to  use  the  extended  fiuger 
of  one  hand  as  a  pleximeter,  and  the  index  or  middle  finger  (or 
both)  of  the  other  hand  as  a  plexor.  Percussion  is  said  to  be 
weak  or  strong^  superficial  or  deep,  according  to  the  energ}'  of  the 
blow  of  the  plexor. 

What  is  to  be  learned  by  percussion  ? 

Percussion  gives  information  as  to  the  relative  distribution  of 
gases  (usually  air),  fluids  and  solids  in  the  structures  examined. 
Attention  is  paid  to  the  quality  (or  timbre),  the  pitch  and  the 
intensity  of  sounds. 

Percussion  of  the  healthy  chest  elicits  a  sound  called  clear, 
representing  the  normal,  pulmonary,  vesicular  resonance.  This 
may  be  impaired  by  increased  density  of  the  pulmonary  tissues 
or  of  superjacent  structures— as  in  interstitial  pneumonitis,  in 
pleural  thickening  or  when  the  chest-wall  is  thickened. 

Percussion-dulness  is  dependent  upon  a  high  degree  of  conden- 
sation— as  in  the  solidification  of  pneumonia,  or  at  the  late  stage 
of  tubercle-formation. 

The  sound  ehcited  over  solid  viscera,  as  the  liver,  heart  or 
spleen,  or  over  serous  effusions — as  in  hydrothorax  or  hydro- 
pericardium,  or  in  ascites,  is  flat. 

The  sound  occasioned  by  air  (or  gas)  in  inclosed  spaces  larger 
than  the  alveoli  of  the  normal  lung  may  be  hyper-resonant  or 
tympanitic — as  in  vesicular  emphysema  or  over  the  intestines. 
11 


162  ESSENTIALS    OF    DIAGNOSIS. 

An  cmiplioric  or  metallic  sound  is  elicited  b}'  percussion  over 
large  closed  cavities,  with  tense  walls,  containing  air— as  a  dis- 
tended stomach  or  a  large  vomica  in  the  lungs. 

A  cracked-pot  or  crackecl-nietal  sound  is  occasioned  by  per- 
cussing over  a  cavity  of  some  size,  with  a  small  opening,  through 
which  air  escapes — as  in  the  case  of  a  pulmonary  cavity  com- 
municating with  a  bronchial  tube. 

The  percussion-sounds  may  display  alterations  in  degree  or 
pitchy  and  in  intensity  or  volume. 

Increased  density  gives  heightened  pitch — hence  a  dull  sound 
is  higher  in  pitch  than  a  clear  one.  The  pitch  of  tympanitic 
sounds  varies.  As  a  rule,  it  is  higher  than  that  of  the  normal 
pulmonary  resonance.  Other  things  being  equal,  the  greater 
the  volume  of  matter  set  in  vibration  the  greater  the  intensity 
of  the  sound. 

By  mediate  percussion  with  the  fingers  a  sense  of  elasticity, 
or  of  resistance,  can  be  appreciated. 

Sometimes  auscultation  is  practised  by  one  while  a  second  at 
the  same  time  practises  percussion— so-called  auscultatory  per- 
cussion. With  a  double  stethoscope  or  phonendoscope  one  may 
practise  auscultatory  percussion  without  assistance.  Some  pre- 
fer simply  to  tap  lightly  over  the  part  to  be  examined,  gradually 
receding  from  or  approaching  to  the  point  of  auscultation. 

The  percussion  sounds  elicited  during  full-held  inspiration 
differ  from  those  elicited  during  full  expiration — so-called  respAra- 
tory  percussion. 

How  is  auscultation  practised  ? 

Auscultation,  like  percussion,  may  be  immediate  or  mediate. 
In  the  former,  the  ear  is  directly  applied  to  the  part  to  be 
auscultated  ;  in  the  latter,  auscultation  is  performed  through 
the  mediation  of  a  stethoscope.  Stethoscopes  are  monaural  or 
binaural.  Each  has  its  advantages.  The  phonendoscope  also 
may  be  employed.  It  is  especially  useful  for  auscultatory  per- 
cussion. The  student  should  become  familiar  with  all  of  the 
methods  of  auscultation. 

What  is  to  be  learned  by  auscultation  of  the  lungs  ? 

Auscultation  gives  information  as  to  the  movement  of  air  and 


PHYSICAL    DIAGNOSIS.  163 

fluids,  as  to  tlic  comparative  calibers  and  lenjjjtlis  of  the  tulles 
through  which  the  air  passes,  and  as  to  the  presence  in  the  path 
of  the  air-current  of  matters  capable  of  acting  the  part  of  reeds 
in  the  production  of  musical  tones. 

Listening  to  the  normal  respiratory  sounds  one  hears  a  soft, 
breezy  inspiration — the  normal  vesicular  rnurinur^  followed  by  a 
scarcely  audible,  briefer  expiration. 

These  sounds  may  be  exaggerated—^^  they  normally  arc  in 
children  ;  hence  they  are  then  c^\\q,(\.  puerile. 

The  respiratory  sounds  are  also  intensified  in  a  lung,  or  in  a 
portion  of  lung,  performing  an  excess  of  function — as  after 
violent  exercise,  or,  compeusatorily,  when  the  function  of  the 
other  lung,  or  of  a  portion  of  the  same  lung,  is  interfered  with 
by  condensation  or  compression. 

The  respiratory  murmur  is  enfeebled  or  wanting  w^hen  there 
is  an  obstruction  to  the  circulation  of  air  in  the  lung — as  in 
incipient  pulmonary  tuberculosis,  and  in  occlusion  of  the  air- 
passages— as  by  intrathoracic  aneurism,  or  when  the  air  vesicles 
have  lost  their  elasticity — as  in  emphysema. 

The  respiratory  murmur  is  rendered  harsh  and  is  heightened  in 
pitch  when  the  bronchial  tubes  are  thickened,  and  their  caliber 
is  narrowed—  as  in  bronchitis.  Under  similar  conditions,  rhonchi 
or  dry  rales  may  be  heard— Si6z7a«f,  if  generated  in  the  small 
tubes  ;  sonorous^  if  generated  in  the  large  tubes.  Sometimes  the 
sounds  are  high-pitched  and  luheezing.  Isolated  sibilant  rales  are 
usually  indicative  of  pulmonary  tuberculosis. 

If  the  vesicular  murmur  is  but  partially  obliterated,  the 
breathing  is  called  vesiculo-bronchial ;  or  if  the  bronchial  element 
predominates,  broncho-vesicular.  When  occlusion  of  the  alveoli 
entirely  obliterates  the  vesicular  quality,  the  breathing  is  said 
to  be  bronchial  or  tubular  or  blowing ;  these  terms  respectively 
indicating  progressive  encroachment  upon  the  integrity  of  the 
smaller  air-tubes.  In  case  of  a  cavity  in  the  lung,  the  breathing 
may  be  cavernous;  if  the  cavity  have  a  tense  wall  and  a  small 
oritice  of  communication  with  a  bronchus,  the  sound  transmitted 
to  the  ear  is  amphoric. 

The  presence  of  secretion  in  the  bronchial  tubes  occasions 


164  ESSENTIALS    OF   DIA(JNOSIS. 

rdles^  usually  qualified  as  mcmt :  .subcrejyitant,  if  in  the  smaller 
tubes,  mucous  if  ijii  the  larger.  * 

The  presence  of  fluid  in  a  vomica  may  give  rise  to  hubbling 
or  gurgling. 

The  separation  of  the  adherent  surfaces  of  pulmonary  alveoli 
lined  by  viscid  secretion,  as  in  pneumonia,  gives  rise  to  the 
crepitant  rale.  When  isolated  softening  of  pulmonary  tubercles 
takes  place,  a  sound  is  generated  comparable  to  that  produced 
when  salt  is  thrown  upon  fire,  or  when  a  few  hairs  are  rul)bed 
together  between  the  fingers — so-called  crackling. 

When  moist  rales  are  heard  through  solidified  pulmonary 
tissues  they  are  transmitted  with  a  peculiar  clearness  and  with 
a  sort  of  ringing  character.     They  are  then  called  consonating. 

In  the  first  stage  of  pleurisy,  before  efl'usion  has  taken  place, 
and  in  the  third  stage,  after  the  fluid  poured  out  has  been 
absorbed,  a  coarse  cracMing^  or  creaking^  or  rasping  sound  of 
pleural /7-2ctio7t  may  be  heard. 

Metallic  tinkling^  resembling  the  splashing  of  water  in  a  pool, 
may  be  heard  when,  in  the  presence  of  a  collection  of  air  in  a 
cavity  large  enough  to  act  as  a  resonating  chamber,  bubbles  of 
air  escape  through  fluid,  fluid  drops  into  fluid,  or  air  enters 
through  a  valve-like  orifice.  These  conditions  are  fulfilled  in 
pneumothorax,  hydropneumothorax,  and  voniicx  of  large  size,  espe- 
cially those  containing  a  moderate  quantity  of  fluid.  When 
air  and  fluid  are  both  present,  shaking  of  the  patient,  with  the 
ear  applied  to  the  chest,  may  elicit  the  sound  of  splashing — the 
so-called  Hippocratic  succussion  sound. 

When  the  ear  is  applied  to  the  normal  chest  of  a  speaking  in- 
dividual a  confused  sound  is  heard — the  vocal  resonance. 

If  fluid  is  efl'used  into  the  pleural  cavity  the  transmission  of 
the  voice  is  intercepted  below  the  upper  level  of  the  fluid.  If 
the  pulmonary  tissues  are  solidifled,  as  in  pneumonia  and  tuber- 
culosis, the  resonance  is  increased,  constituting  hronchopjliony. 
When  spoken  language  and  whispers  can  be  distinguished,  the 
phenomena  are  termed  pectoriloquy  and  wliispering  pectoiiloquy 
respectively.  The  latter,  if  circumscribed,  is  usually  indicative 
of  the  existence  of  a  cavity  in  the  lung. 

AVhen,  in  the  course  of  pleurisy,  a  small  quantity  of  fluid  has 


ACUTE    PLEURISY.  165 

been  poured  out  the  voice  is  transmitted  above  the  level  of  the 
fluid  with  a  peculiar  bleating  character,  constituting  eyopliony. 

Not  only  may  the  character  of  the  breath-sounds  be  altered, 
but  their  rhythm  may  deviate  from  the  normal.  Thus,  expiration 
may  bo  'prolonged,  when,  as  in  emphysema,  the  elasticity  of  the 
walls  of  the  alveoli  is  diminished  or  when  the  alveoli  are  com- 
pressed by  infiltration  around  them,  as  in  incipient  tuberculo- 
sis; or  the  expiratory  sound  may  be  prolonged  or  jerking,  when, 
as  in  the  early  stages  of  pulmonary  tuberculosis,  there  is  some 
obstruction  to  the  exit  of  air. 

Acute  Pleurisy. 

What  are  the  symptoms  of  acute  pleurisy  ? 

Acute  pleurisy  may  set  in  with  a  chill  and  sharp  pain  in  the 
side,  aggravated  by  the  respiratory  movements.  The  dyspnea 
may  be  slight  or  considerable.  The  temperature  rises  moderately 
high  ;  the  breathing  is  feeble,  shallow  and  rapid.  There  is  slight 
irritative  cough,  and  scanty,  frothy  expectoration.  In  the  course 
of  a  few  days  the  symptoms  subside,  and  at  the  end  of  a  week  or 
ten  days  the  patient  is  well.  Acute  pleurisy  may  occur  as  a 
primary  condition.  It  may  follow  traumatism  or  exposure  to 
cold.  Quite  commonly  it  is  secondary  to  inflammation  of  adja- 
cent structures,  especially  of  the  lungs.  It  also  occurs  in  the 
course  of  various  infectious  diseases,  of  nephritis  and  of  rheuma- 
tism. Pleurisy  may  be  "dry"  or  attended  wdth  effusion.  The 
exudation  may  be  serous,  sero-fibrinous,  purulent  or  hemor- 
rhagic. Effusion  gives  rise  to  respiratory  and  circulatory  em- 
barrassment proportionate  to  the  volume  of  fluid  poured  out. 
It  may  be  encysted. 

The  fluid  poured  out  may  not  be  readily  absorbed.  On  the 
contrary,  it  may  remain  obstinately  persistent.  In  the  course 
of  time,  it  may  become  purulent  ;  under  other  circumstances,  it 
is  purulent  from  the  outset ;  in  either  case  the  condition  is 
known  as  empyema.  More  commonly,  the  fluid  is  absorbed  and 
the  two  layers  of  the  pleura  become  adherent,  with  obliteration 
of  the  pleural  cavity  ;  in  the  progress  of  the  case  considerable 
thickening  takes  place,  followed  in  turn  by  retraction  of  the 


166  ESSENTIALS    OF    DIAGNOSIS. 

chest.  When  the  effusion  is  purulent  there  are  repeated  rigors, 
fever,  sweats,  leukocytosis,  edema  of  the  chest  and  eniaciation  ; 
otherwise  the  health  may  be  preserved,  unless  the  chronic  pleu- 
risy is  tuberculous.  By  the  action  of  the  heart,  pulsation  may 
be  imparted  to  a  collection  of  fluid  in  the  left  pleural  cavity,  so 
that  an  aneurism  may  be  simulated.  When  the  collection  is 
purulent,  the  condition  is  designated  pulsatory  empyema.  Pleu- 
risy may  be  confined  to  the  diaphragmatic  layer  or  to  the  folds 
between  the  lobes  of  the  lungs. 

What  are  the  physical  signs  of  acute  pleurisy  ? 

For  convenience  of  study,  the  physical  signs  of  acute  pleurisy 
may  be  considered  in  three  stages.  In  the  first.,  or  plastic  stage, 
as  the  surfaces  of  the  two  layers  of  the  pleura,  roughened  by 
exudation,  slide  over  one  another  in  inspiration  and  expiration, 
a  harsh,  creaking  sound  is  heard,  the  vibration  occasioning 
which  may  sometimes  also  be  appreciable  on  palpation — the 
so-called  friction-sound  or  nib.  The  breathing  is  shallow,  feeble 
and  rapid  ;  the  movements  of  the  affected  side  being  restrained 
in  the  greater  degree  in  order  to  mitigate  the  pain. 

In  the  second  stage.,  or  stage  of  effusion,  serum  in  variable 
q^uantity,  possibly  mixed  with  blood,  is  poured  out  into  the 
pleural  cavity.  The  corresponding  lung  is  pushed  upward  and 
backward,  and  the  heart,  liver,  spleen  and  diaphragm  may  be 
displaced.  One  side  of  the  chest  appears  larger  than  the  other, 
and  the  interspaces  corresponding  to  the  situation  of  the 
effusion  are  abnormally  prominent.  The  cardiac  impulse  is 
visibly  displaced.  The  resjnratory  excursion  is  limited.  Below 
the  upper  level  of  the  fluid  the  percussion-note  is  flat  ;  above,  it 
is  subtympanitic.  Through  the  effusion  the  breath-sounds  are 
heard  feebly  and  indistinctly  ;  the  voice-vibrations  are  not  trans- 
mitted to  the  palpating  hand  ;  nor,  as  a  rule,  to  the  auscultating 
ear,  though  exceptionally  bronchophony  may  exist.  To  the  ear 
applied  to  the  chest  above  the  level  of  the  fluid  the  voice  may 
be  transmitted  with  a  peculiar  bleating  quality— constituting 
egophony.  Exploratory  puncture  may  be  necessary  to  deter- 
mine the  presence  of  fluid  and  its  character. 

In  the  third  stage,  the  effusion  has  been  absorbed  and  the 
apposed  layers  of  pleura  again  come  in  contact.    The  friction- 


ACUTE   PLEURISY.  167 

sound  of  the  first  stage  returns.  Ultimately  the  pleura  may- 
be restored  to  its  original  condition  or  its  apposed  surfaces 
may  become  adherent  and  thickened,  giving  rise  to  retraction 
of  the  chest  and  percussion -dulness. 

How  does  acute  pleurisy  differ  from  croupous  pneumonia? 

Pleurisy  usually  accompanies  pneumonia.  The  signs  of  the 
former,  however,  should  not  be  permitted  to  obscure  the  exist- 
ence of  the  latter.  Neither  the  local  nor  the  general  symptoms 
of  pleurisy  are  so  profound  as  those  of  pneumonia.  While 
pneumonia  may  then  present  the  symptoms  of  pleurisy,  pleurisy 
does  not  present  the  blood-streaked  expectoration,  the  crepitant 
rale,  the  blowing  breathing,  the  deficiency  of  the  chlorides  in 
the  urine,  or  the  critical  termination  of  pneumonia. 

The  percussion-note  of  pneumonia  is  dull ;  that  of  pleurisy, 
when  an  eftusion  exists,  is  flat.  The  dulness  of  pneumonia  is 
usually  over  a  lower  lobe  ;  that  of  pleurisy  is  uuiversally  at  the 
base.  In  pleurisy,  the  breath-sounds  are  heard  feebly,  or  not 
at  all,  through  the  effusion  ;  in  pneumonia  the  breathing  is 
bronchial.  Vocal  resonance  and  fremitus  are  increased  in 
pneumonia  ;  they  are  diminished  or  absent  in  pleural  effusion  ; 
above  the  fluid,  however,  a  bleating  sound  is  transmitted  to  the 
auscultating  ear.  Simple,  uncomplicated  pneumonia  is  un- 
attended with  friction-sounds  and  occasions  no  dis.placement  of 
adjacent  viscera. 

How  are  intercostal  neuralgia  and  acute  pleurisy  to  be  dif- 
ferentiated ? 
The  pain  of  intercostal  neuralgia  may  simulate  that  of  acute 
pleurisj^,  and  give  rise  to  rapid,  shallow,  feeble  respiratory 
movements.  Intercostal  neuralgia  is  paroxysmal  and  unat- 
tended with  friction-sound,  dulness  on  percussion  or  fever ; 
it  occurs  in  anemic  individuals  with  neurotic  tendencies,  and 
may  be  attended  with  a  unilateral  herpetic  eruption  in  the 
course  of  the  nerve  affected.  In  addition  there  are  a  number  of 
tender  points. 

How  are  a  pleuritic  effusion  and  an  hydatid  cyst  of  the  liver 
to  be  differentiated  ? 
When  an  hydatid  cyst  of  the  liver  attains  proportions  suf- 


168  ESSENTIALS   OP   DIAGNOSIS. 

ficient  to  give  rise  to  definite  physical  phenomena,  these  will 
appear  in  a  region  beyond  that  in  which  the  signs  of  a  pleuritic 
effusion  on  the  right  side  are  found.  The  history  of  an  acute 
attack  is  wanting,  while  it  is  present  in  pleuritic  effusion. 
Neither  in  case  of  pleuritic  effusion,  nor  in  case  of  hydatid  of 
the  liver,  is  the  percussion-dulness  confined  to  the  right  hypo- 
chondriuni  ;  in  the  one  it  extends  rather  upwards,  in  the  other 
downwards  ;  in  the  latter  it  is  associated  with  fluctuation.  In 
a  case  of  hydatid  cyst  it  may  by  percussion  be  possible  to  elicit 
the  characteristic  thrill  or  fremitus.  In  a  case  of  pleuritic 
effusion  the  breath-sounds  and  the  vibrations  of  the  voice  are 
feebly  transmitted  ;  breath-sounds,  vocal  resonance,  and  fremitus 
are  unaltered  in  hydatid  cyst  of  the  liver.  Egophony  is  char- 
acteristic of  the  presence  of  fluid  in  the  pleura  ;  it  is  thus 
not  present  in  case  of  hydatid  cyst  of  the  liver.  Exploratory 
puncture  may  determine  the  presence  of  hydatid  booklets,  the 
detection  of  which  places  the  diagnosis  beyond  doubt. 

How  are  a  pleuritic  effusion  and  abscess  of  the  liver  to  be  differ- 
entiated ? 
Symptoms  of  respiratory  interference  are  naturally  less  con- 
spicuous in  case  of  abscess  of  the  liver  than  in  case  of  pleuritic 
effusion.  Hepatic  abscess  may  occasion  tumefaction  in  the 
right  hypochondrium  ;  pleural  eftusion  renders  the  chest  asym- 
metrical from  unilateral  bulging.  Pleuritic  effusion  impairs 
the  transmission  of  the  breath-sounds  and  of  the  vibrations  of  the 
voice,  which  is  unaltered  by  an  hepatic  abscess.  Egophony  may 
be  elicited  in  case  of  pleuritic  effusion,  but  not  in  case  of  hepatic 
abscess.  Rigors  commonly  attend  an  abscess  of  the  liver  ;  they 
only  take  place  in  cases  of  pleuritic  effusion  when  suppuration 
has  occurred.  In  case  of  hepatic  abscess,  there  is  usually  a 
history  of  gallstone,  of  ulceration  of  the  bowel  or  of  pyemia  ; 
in  case  of  pleuritic  effusion,  there  is  a  history  of  an  acute  attack 
of  pleurisy.  Hepatic  abscess  and  perihepatitis  may,  however, 
give  rise  to  pleural  effusion  by  extension. 

How  are  pleuritic  effusion  and  abscess  of  the  spleen  to  be  differ- 
entiated? 

Abscess  of  the  spleen  is  most  common  as  a  manifestation  of  py- 


ACUTE   PLEURISY.  169 

emia  ;  pleuritic  effusion  is  a  sequel  of  an  acute  pleurisy.  The 
symptoms  of  respiratory  derangement,  a  necessary  part  of  pleu- 
ritic effusion,  are  subordinate  in  case  of  splenic  abscess.  Re- 
peated rigors  occur  in  abscess  of  the  spleen  ;  rigors  occur 
in  case  of  empyema,  but  not  when  the  effusion  is  not  purulent. 
Egophony  may  be  developed  when  fluid  is  present  in  the  pleu- 
ral cavity,  but  not  in  case  of  splenic  abscess. 

How  is  an  intra-thoracic  tumor  to  be  distinguished  from 
chronic  pleurisy  ? 
Tumors  in  the  chest  may  arise  from  the  pleura  or  from  the 
lung ;  they  ma}'^  develop  in  the  mediastinum  ;  or  they  may 
be  aneurismal.  Malignant  tumors  are  secondary  to  growths 
elsewhere — an  element  in  diagnosis.  They  give  rise  to  circum- 
scribed areas  of  dulness  on  percussion,  not  necessarily  limited 
to  one  side  ;  to  enfeebled  breathing  and  perhaps  friction-sounds  ; 
in  their  physical  signs,  they  more  closely  resemble  encysted 
pleurisy  than  ordinary  chronic  pleurisy.  When  actually  com- 
plicated b}^  pleurisy,  the  diagnosis  may  not  be  possible.  Aneu- 
risms occur  in  the  course  of  the  aorta  and  large  vessels,  and,  in 
addition  to  the  evidences  of  tumor,  are  accompanied  by  thrill, 
bruit  and  pulsation. 

How  are  a  pleuritic  effusion  and  hydrothorax  to  be  differ- 
entiated ? 

Hydrothorax  or  passive  pleural  effusion  occurs  as  a  result  of 
cardiac  insufficiency  or  as  a  part  of  a  general  dropsy,  from 
nephritis,  for  instance. 

The  effusion  of  hydrothorax  is  usually  bilateral;  that  of  pleu- 
risy is  almost  invariably  unilateral.  In  the  latter  there  'has 
probably  been  antecedent  pain  and  friction-sounds  and  also 
fever ;  in  the  former  there  are  other  evidences  of  cardiac  fail- 
ure or  of  a  general  dropsy.  The  fluid  obtained  on  exploratory 
puncture  in  case  of  inflammatory  effusion  is  usually  richer  in 
salts  and  albumin  than  the  simple  serous  effusion  of  non-in- 
flammatory origin. 

How  is  a  pericardial  effusion  to  be  distinguished  from  a  pleu- 
ral effusion  ? 
A  pericardial  effusion  occurs  under  circumstances  similar  to 


170  ESSENTIALS   OP    DIAGNOSIS. 

those  that  give  rise  to  a  pleural  effusion— as  a  result  of  in- 
flammation or  as  a  part  of  a  general  dropsy.  The  position  and 
outline  of  the  percussion-dulness  to  which  a  pericardial  effusion 
gives  rise,  however,  are  entirely  different  from  what  is  found  in 
a  case  of  pleural  effusion  ;  nor  are  the  hreath-sounds  notably  in- 
terfered with,  while  the  circulation  is  embarrassed  and  the 
heart-sounds  are  almost  obliterated  at  the  cardiac  apex. 


Chronic  Pleurisy. 

What  are  the  clinical  features  of  chronic  pleurisy? 

The  exudation  of  acute  pleurisy  may  not  be  absorbed,  and, 
even  without  acute  symptoms,  adhesions  may  form  between 
the  two  layers  of  pleura,  with  secondary  thickening.  As  a 
result  one  side  of  the  chest  may  undergo  retraction  and  flatten- 
ing, while  the  percussion-resonance  is  impaired,  the  breath- 
sounds  distant  or  enfeebled,  the  vocal  resonance  and  fremitus 
diminished.  Breathing  may  be  interfered  with,  the  heart  dis- 
placed and  health  may  suffer  in  varying  degree.  Sometimes 
the  extremities  of  the  fingers  and  toes  become  enlarged  and 
bulbous  and  the  finger-nails  unduly  curved  and  beak-shaped. 


Acute  Bronchitis. 

What  are  the  symptoms  of  acute  bronchitis  ? 

Acute  bronchitis  results  from  exposure  to  cold,  the  inhalation 
of  irritating  fumes,  or  as  a  secondary  disorder  in  the  course  of 
fevers,  rheumatism  or  heart-disease.  There  is  irritative  cough, 
and,  at  first,  scanty  mucous  expectoration,  which  subsequently 
becomes  more  copious  and  muco-purulent ;  slight  elevation  of 
temperature  ;  increased  frequency  of  respiration  ;  some  dyspnea  ; 
retro-sternal  pain,  and  mild  constitutional  symptoms. 

What  are  the  physical  signs  of  acute  bronchitis  ? 

The  chest  is  not  deformed  and  expands  well.  The  i^erciission- 
resoiiance  is  vesicular.     The  breathiny  is  liarsh  at  first ;  dry  rales, 


CHROMC    BRONCHITIS.  171 

sonorous  and  sibilant,  are  heard  ;  subsequently  large  and  small 
moist  rales.  Vocal  resonance  and  fremitus  are  not  perceptibly 
altered. 

How  does  acute  bronchitis  differ  from  acute  miliary  tubercu- 
losis ? 

In  acute  miliary  tuberculosis  the  dyspnea  is  greater,  the  tem- 
perature is  higher,  with  greater  oscillations,  the  breathing  is 
more  rapid,  and  the  symptoms  are  more  profound  than  in  acute 
bronchitis.  The  further  progress  of  the  case  clears  up  any  pos- 
sible doubt.  Eecover}'  from  acute  bronchitis  is  the  invariable 
rule.  Pulmonary  consolidation  and  softening,  percussion -dul- 
ness  and  fine  moist  rales,  emaciation,  hectic  fever,  gradual  fail- 
ure of  the  vital  powers  and  ultimately  death  mark  the  usual 
course  of  acute  miliary  tuberculosis. 


Chronic  Bronchitis. 

What  are  the  symptoms  of  chronic  bronchitis  ? 

Chronic  bronchitis  is  usually  a  result  of  repeated  attacks  of 
acute  bronchitis  ;  it  may  manifest  itself  as  a  special  suscepti- 
bility to  acute  bronchitis  ;  at  first  it  appears  as  a  winter  cough, 
subsequently  becoming  continuous.  It  may  obstinately  resist 
treatment  ;  it  is  attended  with  a  good  deal  of  cough,  copious 
muco-purulent  expectoration,  marked  shortness  of  breath,  and 
may  in  time  give  rise  to  emphysema,  or  to  bronchiectasis.  It  is 
often  attended  with  loss  of  flesh  and  strength. 

What  are  the  physical  signs  of  chronic  bronchitis  ? 

If  emphysema  coexists  the  chest  may  be  enlarged  ;  otherwise 
it  is  not  abnormal  in  size  or  form  ;  the  resjnratoi'y  excursion  is 
somewhat  diminished  ;  the  percussion-resonance  is  little  or  not 
at  all  impaired  ;  the  breathing  is  harsh  and  may  be  feeble,  the 
bronchial  element  preponderating.  Coarse  rales,  moist  and 
dry,  are  heard  at  all  parts  of  the  chest.  Vocal  fremitus  and 
resonance  are  rather  increased. 


172  ESSENTIALS    OP    DIAGNOSIS. 

How  is  chronic  bronchitis  to  be  distinguished  from  interstitial 
pneumonitis  ? 
A  certain  degree  of  bronchitis  commonly  attends  interstitial 
pneumonitis  ;  but  the  cliest  is  likely  to  undergo  retraction,  which 
is  not  the  case  in  bronchitis.  If  impairment  of  resonance  attend 
chronic  bronchitis,  it  is  general  and  not  well  defined,  while  the 
dulness  of  interstitial  pneumonitis  is  the  more  circumscribed 
and  the  more  decided. 

How  does  chronic   bronchitis   differ  from  pulmonary  tuber- 
culosis ? 

While  chronic  bronchitis  may  be  attended  with  obstinate 
cough,  muco-purulent,  sometimes  blood-streaked,  expectoration, 
loss  of  flesh  and  strength,  the  physical  signs  are  general  in  their 
distribution  and  not  localized  as  in  tuberculosis.  The  impair- 
ment of  resonance  is  not  so  great  in  chronic  bronchitis  as  it  is  in 
tuberculosis.  The  elevation  of  temperature  observed  in  tuber- 
culosis is  wanting  in  bronchitis.  Tubercle-bacilli"  are  not  found 
in  the  sputum  of  cases  of  simple  chronic  bronchitis. 

Plastic  Bronchitis — Fibrinous  Bronchitis, 

What  are  the  characteristics  of  plastic  or  fibrinous  bronchitis  ? 

In  addition  to  the  phenomena  of  ordinary  bronchitis,  there 
are  present  in  plastic  bronchitis  decided  dyspnea  and  cyanosis, 
together  with  the  expectoration  of  tough,  fibrinous  casts  of  the 
smaller  bronchial  tubes  ;  there  occur  lancinating  pains  in  the 
chest ;  and  there  may  be  bleeding  from  the  nose  and  mouth. 

Putrid  Bronchitis. 

What  are  the  clinical  features  of  putrid  bronchitis  ? 

In  case  of  bronchitis  with  bronchial  dilatation,  accumulation 
of  secretion  may  take  place,  with  ulceration  and  inflammation 
of  the  bronchial  mucous  membrane,  as  a  consequence  of  which 
expectoration  is  augmented,  the  breath  and  sputa  possessing  an 
offensive,  fetid  odor.  To  these  phenomena  fever  and  a  typhoid 
condition  may  be  added— and  even  pulmonary  gangrene  may 
supervene. 


BRONCHIECTASIS.  173 

Bronchiecta^iSc 

What  is  bronchiectasis  ? 

Bro)icliicctasii<  consists  in  a  cylindrical  or  saccular  dilatation 
of  the  bronchial  tubes,  usually  developed  in  the  course  of  some 
condition  attended  with  powerful  or  sustained  expiratory 
efibrts — such  as  chronic  bronchitis.  It  may  also  result  from 
contraction  of  the  peribronchial  tissues.  In  addition  to  the 
symptoms  of  the  causative  afiection,  the  characteristic  feature 
of  bronchiectasis  is  the  periodical  occurrence  of  paroxysms  of 
cough,  attended  with  the  expectoration  of  large  quantities  of 
muco-purulent  secretion  of  offensive  odor.  The  tubes  filled  with 
fluid  may  give  rise  in  small  areas  of  irregular  distribution  to 
jjercussion-dulness  that  disappears  with  the  evacuation  of  the 
fluid.  On  auscultation  large,  coarse,  moist  rales  and  gurgling 
may  be  heard.  If  of  moderately  large  size,  bronchiectatic  cavi- 
ties may  yield  a  hyper-resonant  percussion-note,  with  blowing 
breathing  and  whispering  pectoriloquy. 

How  does  bronchiectasis  differ  from  pulmonary  gangrene  ? 

The  grave  constitutional  symptoms  of  gangrene  are  lacking 
in  bronchiectasis.  The  expectoration  of  both  is  offensive,  but 
that  in  gangrene  is  actually  fetid.  The  sputum  of  gangrene  con- 
tains shreds  of  pulmonary  tissue ;  that  of  bronchiectasis  does  not. 

How  does  bronchiectasis  differ  from  pulmonary  abscess  ? 

A  sacculated  dilatation  of  a  bronchial  tube  containing  fluid 
fulfils  the  physical  conditions  of  an  abscess  communicating  with 
a  bronchial  tube.  The  expectoration  of  a  case  of  bronchial  dila- 
tation, however,  has  an  offensive  odor  not  present  in  abscess. 
The  fever  and  sweats  of  abscess  are  wanting  in  bronchiectasis. 
Abscess  is  usually  a  sequel  or  complication  of  pulmonary  in- 
flammation or  some  general  pyemic  process. 

How  are  bronchiectasis  and  catarrhal  pneumonia  to  be  differ- 
entiated ? 
In  the  small  areas  of  dulness  of  irregular  distribution,  bron- 
chiectasis may  simulate  catarrhal  pneumonia,  but  the  former 
is  wanting  in  the  febrile  phenomena  and  the  constitutional  de- 
pression of  the  latter  disease.    Catarrhal  pneumonia  is  a  disease 


174  ESSENTIAhS    OF    DIAGNOSIS. 

of  acute  onset,  though  sometimes  of  protracted  duration  ;  while 
bronchiectasis  is  essentially  a  chronic  disease.  The  one  is  most 
common  in  childhood,  the  other  later  in  life.  The  offensive  sputa 
of  bronchiectasis  are  entirely  wanting  in  catarrhal  pneumonia. 

Capillary  Bronchitis. 

What  are  the  symptoms  of  capillary  bronchitis  ? 

Gapillarij  bronchitis,  sometimes  called  suffocative  catarrh^  is  an 
inflammation  of  the  smallest  or  "capillary"  bronchi,  most  com- 
mon in  children  and  in  old  persons,  and  usually  secondary  to 
bronchitis  of  the  larger  tubes.  In  addition  to  the  symptoms 
of  the  latter  affection,  capillary  bronchitis  is  attended  with  de- 
cided constitutional  depression  ;  the  dyspnea  is  more  profound, 
and  cyanosis  may  be  marked. 

Cough  is  severe,  while  expectoration  is  scanty  ;  the  pulse  is 
rapid,  the  respirations  hurried,  the  countenance  discolored,  the 
expression  anxious  ;  fever  is  moderately  high. 

What  are  the  physical  signs  of  capillary  bronchitis  ? 

The  chest  is  symmetrical.  The  breathing  is  rapid  and  shallow. 
The  percussion-resonance  is  vesicular,  though  in  spots  it  may  be 
slightly  impaired.  When  it  exists,  the  impairment  of  resonance 
does  not  depend  upon  exudation,  but  upon  atelectasis.  The 
phenomenon  may,  therefore,  be  inconstant,  and  its  location 
shifting.  The  breath-sounds  are  harsh,  and  in  many  places  in 
both  lungs  small,  mucous  rales  may  be  heard. 

Vocal  resonance  and  fremitus  are  slightly  increased.  The  de- 
viations from  the  normal  are  most  marked  at  the  bases  of  the 
lungs  posteriorly. 

How  are  capillary  bronchitis  and  acute  miliary  tuberculosis 
to  be  differentiated  ? 

Capillary  bronchitis  is  a  quite  brief  disease  of  the  very  young 
and  the  very  old  ;  acute  miliary  tuberculosis  is  a  more  prolonged 
disease  of  the  young  and  of  adults.  Dyspnea,  cyanosis  and 
constitutional  depression  are  early  more  decided  in  capillary 
bronchitis  than  in  acute  miliary  tuberculosis.  The  fever  of 
tuberculosis  is  more  intense  and  vacillating  than  that  of  bron- 
chitis.   Localized  areas  of  persistent  percussion-dulness,  followed 


C  A  T  A  II  nil  A  L    A  N  D    B  It  ()  \  ('  1 1  O  -  P  N  K  l'  .M  O  N  I  A  .         175 

by  the  moist  rales  of  softening,  may  develop  in  the  course  of 
acute  miliary  tuberculosis,  which  is  progressively  fatal ;  recovery 
from  capillary  bronchitis  is  not  uncommon. 

Catarrhal  Pneumonia — Broncho-pneumonia. 

What  are  the  symptoms  of  catarrhal  pneumonia? 

Catarrhal  piuunionla^  also  called  lobular  pneumonia^  ovhronrJio- 
pneumonilis^  may  be  apparently  primar}-,  but  is  often  secondary 
to  capillary  bronchitis,  as  also  to  measles,  influenza  and  other 
constitutional  afiections  ;  it  may  result  from  the  inspiration  of 
infectious  material,  whether  contained  in  the  food  or  from 
septic  surfaces  in  the  respirator}'  tract. 

It  is  attended  with  cough,  muco-purulent  expectoration, 
dyspnea,  increased  frequency  of  respiration,  decided  fel)rile 
phenomena  that  may  be  hectic,  and  constitutional  depression. 
The  course  of  the  disease  may  be  protracted. 

What  are  the  physical  signs  of  catarrhal  pneumonia  ? 

The  chest  is  symmetrical ;  respiration  is  shallow. 

The  range  of  movement  is  sometimes  curtailed  on  one  side. 

Small,  irregularly  distributed  patches  of  percussion-diilness 
may  be  found  here  and  there  over  both  sides  of  the  chest,  an- 
teriorly' and  posteriorly  ;  the  breathing  is  harsh  ;  fine  and  large 
moist  rales  may  be  heard  ;  the  vocal  resonance  and  fremitus  are 
intensified  in  patches  corresponding,  as  a  rule,  to  the  areas  of 
percussion-dulness. 

How  does  catarrhal  pneumonia  differ  from  capillary  bron- 
chitis'? 

The  gravity  of  the  symptoms  in  both  depends  upon  the  extent 
of  the  disease.  Other  things  being  equal,  capillar}'  bronchitis 
is  the  more  acutely  dangerous  affection,  the  depression  some- 
times being  profound.  The  duration  of  catarrhal  pneumonia  is 
the  longer.  Its  febrile  phenomena  are  the  more  decided,  and 
its  temperature-range  is  marked  by  great  oscillations.  The 
impairment  of  percussion-resonance  is  more  decided  in  catar- 
rhal pneumonia  than  in  capillary  bronchitis  ;  it  is  constant,  and 
does  not  change  its  seat. 


176  ESSENTIALS    OP    DIAGNOSIS. 

What  are  the  means  of  distinguishing  atelectasis  from  catar- 
rhal pneumonia? 
Atelectasis  is  the  pre-natal  condition  of  the  lungs,  before  they 
have  been  inflated  with  air.  It  may  also  arise  in  the  course  of 
aflectious  attended  with  inspiratory  obstruction  of  the  bronchial 
tubes,  as  in  whooping-cough  or  capillary  bronchitis,  for  instance, 
a  plug  of  mucus  acting  as  a  ball-valve,  allowing  the  expiration 
of  air  but  preventing  inspiration.  It  is  said  also  to  occur  in 
parts  of  the  lung  functionally  inactive.  The  condition  is  not 
an  inflammatory  one  and  is  not  necessarily  attended  with  eleva- 
tion of  temperature,  as  is  catarrhal  pneumonia.  The  collapse 
is  not  persistent,  but  may  successively  involve  different  parts  of 
the  lung  ;  so  that  the  physical  signs  are  not  constant,  but  tran- 
sitory as  well  as  migratory. 

How  does  catarrhal  pneumonia  differ  from  pulmonary  infarc- 
tion ? 

Catarrhal  pneumonia  does  not  set  in  with  the  acuteness  and 
the  severe  pain  of  pulmonary  infarction  ;  nor  is  the  expectora- 
tion as  persistently  blood-streaked  in  the  former  as  in  the  latter. 
Catarrhal  pneumonia  is  attended  with  decided  febrile  manifes- 
tations and  is  of  considerable  duration,  while  pulmonary  infarc- 
tion scarcely  occasions  fever  and  its  symptoms  soon  subside. 
The  detection  of  a  source  of  an  embolus  would  be  strongly  in 
favor  of  the  existence  of  infarction. 

Acute  Croupous  Pneumonia. 

What  are  the  symptoms  of  croupous  pneumonia? 

Croupous  pneumonia,  also  called  lobar  pneumonia,  and  at  one 
time  lung  fever,  is  an  acute,  infectious  disease  dependent  upon 
the  invasion  of  microorganisms,  of  which  the  most  common  is 
the  encapsulated  lanceolate  diplococcus.  (Fig.  22.)  It  is  the 
most  widely  distributed  and  the  most  ftital  acute  disease.  The 
susceptibility  and  the  mortality  increase  progressively  after  the 
fifteenth  year.  Males  suffer  in  greater  number  than  females, 
and  the  disease  is  more  common  in  the  city  than  in  the  coun- 
try.    Intemperance  and  other  debilitating  influences  are  pre- 


ACUTE    CROUPOirS    PNEUMONIA 


177 


disposing  causes.  The  disease  often  follows  exposure  to  cold, 
setting  in  suddenly  with  a  chill,  sometimes  with  convulsions,  the 
temperature  rising  at  once  to  103°  or  104°  F.,  the  respiratory 
frequency  reaching  35,  40,  50  or  more,  while  the  j^^lse  is  not 
proportionately  accelerated. 

There  is  at  first  slight  cough,  with  scanty  expectoration  of  a 
viscid  sputum,  which  soon  becomes  blood-streaked  (rusty),  and 
usually  contains  the  causative  microorganisms. 

There  is  considerable  dyspnea ;  the  alse  nasi  are  retracted  in 
breathing;  and  one  or  both  cheeks  are  flushed.  As  a  rule  the 
number  of  colorless  blood-corpuscles  is  increased  until  the  crisis 
occurs. 

The  cough  increases  ;  the  expectoration  becomes  more  free, 
more  hemorrhagic,  less  viscid,  and  presents  the  appearance  of 
prune-juice.  There  is  pain  in  the  chest,  often  referred  to  the 
nipple  of  the  affected  side  ;  usually  involving  the  lateral  or  axil- 
lary region  in  addition.  The  pain  is  increased  on  attempting  to 
make  prolonged  inspiration.     The   lips  and  cheeks  may  be  cya- 

FiG.  22. 


Micrococci  of  croupous  pneumonia.     (Vierordt.) 

notic.  The  toyigue  is  coated  ;  the  appetite  is  lost ;  thii^st  is  in- 
creased ;  there  may  be  jaundice,  and,  at  the  height  of  the  attack, 
delirium. 

Between  the  second   and  fifth  days,  herpes  of  the  lips  may 
appear.     The  symptoms  continue  for  from  five  to  seven  or  nine 
days,  to  subside  by  crisis.     Profuse  perspiration  occurs  ;   the 
temperature  declines  ;  and  convalescence  sets  in. 
12 


178  ESSENTIALS    OF    DIAGNOSIS. 

The  congh  is  still  free ;  the  expectoration  copious  and  muco- 
purulent. During  the  attack  the  urine  is  deficient  or  wanting 
in  chlorides,  which  return  as  resolution  proceeds.  Headache, 
delirium  and  other  toxic  symptoms  may  be  present.  Resolu- 
tion may  fail  to  take  place  or  it  may  be  but  partial ;  so  that 
suppuration  or  gangrene  may  ensue  or  chronic  induration  be  a 
sequel.  Death  happens  in  a  variable  proportion  of  cases,  not 
rarely  from  heart-clot  or  heart-fiiilure.  In  the  aged  and  in 
alcoholics  the  disease  may  be  insidious  in  onset  and  latent  in 
course. 

Pleurisy  is  a  common  accompaniment  of  pneumonia.  Occa- 
sionally large  effusions  are  poured  into  the  pleural  cavity. 
Pericarditis,  endocarditis  and  meningitis  may  be  complications. 

What  are  the  physical  signs  of  croupous  pneumonia? 

For  convenience  of  description,  pneumonia  is  divided  into 
three  stages  :  a  stage  of  congestion,  a  stage  of  exudation,  a  stage 
of  resolution. 

What  are  the  physical  signs  of  the  first  stage  of  pneumonia, 
or  the  stage  of  congestion  ? 

The  aspect  of  the  chest  is  unchanged. 

The  breathing  is  accelerated,  becoming  shallow  and  labored. 

The  percussio7i-resonance  is  little  or  not  at  all  impaired. 

The  respiratory  r)iurmur  is  roughened  over  a  circumscribed 
area,  usually  corresponding  to  a  lower  lobe.  At  the  end  of  in- 
spiration a  fine,  moist,  crepitating  rale  may  be  heard. 

Vocal  resonance  and  fremitus  are  not  perceptibly  altered. 

What  are  the  physical  signs  of  the  second  stage  of  pneumonia, 
or  the  stage  of  exudation  ? 

The  respiratory  excursion  is  curtailed  ;  the  breathing  is  hurried. 

The  lower  part  of  the  chest  on  one  side,  corresponding  to  the 
lower  or  middle  lobe  of  the  lung,  may  be  a  little  fuller  than 
elsewhere.  Here  the  percussion-note  is  dull.  Above,  the  note  is 
hyper-resonant.  The  right  lung  appears  to  suffer  more  com- 
monly than  the  left ;  not  rarely  both  become  involved.  Some- 
times the  upper  lobe  is  attacked,  particularly  in  children. 
When  the  disease  is  deep-seated  the  physical  signs  may  be 
ill-defined. 


ACUTE    CROIIPOUS    PNEUMONIA.  170 

At  the  (lull  area,  the  breath inj  in  bronchiiil  in  character. 
At  other  parts  of  the  chest  the  breathiii,;^  is  puerile.  The 
crepitant  ride  has  disappeared.  Small  mucous  n'des  mjiy  be 
heard. 

Vocal  resonance  and  fremitus  are  increased  at  the  area  of  per- 
cussion-dulness.  A  pleuritic  friction-sound  may  be  heard  and 
the  signs  of  effusion  may  develop. 

What  are  the  physical  signs  of  the  third  stage  of  pneumonia,  or 
the  stage  of  resolution  ? 

The  localized  fulness  of  the  chest  ma}'-  remain. 

The  respiratory  excursion  and  the  expansion  have  somewhat 
augmented. 

Some  degree  of  impairment  of  the  percussion-resonance  persists. 

The  breathing  is  yet  bronchial,  though  not  in  the  same  degree 
as  it  was.  A  small  subcrepitant  rale,  termed  the  crepitus  redux, 
can  now  be  heard ;  other  moist  rales  also  become  plainly  dis- 
cernible. 

Vocal  resonance  and  fremitus  are  still  increased. 

How  is  edema  of  the  lungs  to  he  distinguished  from  pneu- 
monia ? 

Pulmonary  edema  may  develop  in  the  course  of  heart-disease, 
if  the  compensation  be  disturbed  ;  in  the  course  of  nephritis  or  in 
the  course  of  general  asthenia  ;  in  subjects  of  these  aftections, 
it  may  follow  exposure.  It  is  not  contined  to  one  lung,  but 
involves  both  alike  throughout  their  entire  extent. 

Pulmonary  edema  may  be  uncomplicated,  but  is  likely  to  he 
associated  with  effusions  into  the  serous  cavities  and  dropsy 
elsewhere.  The  sputum  is  frothy  and  abundant,  but  not  rusty 
or  like  prune-juice.  The  cheeks  are  flushed  in  pneumonia; 
the  face  is  pale  or  livid  in  pulmonary  edema.  Edema  usually 
does  not  present  febrile  symptoms  ;  the  percussion-resonance 
scarcely  suffers  ;  large  and  small  moist  rales  are  heard  all  over 
the  chest ;  the  proportion  of  chlorides  in  the  urine  remains  un- 
altered ;  while  the  brief  duration  of  the  condition,  speedily 
terminating,  as  it  does,  in  recovery  or  in  death,  and  the  knowl- 
ledge  of  the  existence  of  a  condition  that  may  occasion  it,  make 
the  diagnosis  clear. 


180  ESSENTIALS    OF    DIAGNOSIS. 

In  what  respects  do  catarrhal  and  croupous  pneumonia  differ  ? 

Croupous  pneumonia  is  sudden  in  onset ;  catarrhal  pneu- 
monia is  rather  commonly  secondary  to  some  other  condition. 
Lobar  pneumonia  usually  attacks  robust  adults  ;  broncho-pneu- 
monia, children,  the  aged,  the  debilitated.  The  sputum  of 
catarrhal  pneumonia  is  not  often  blood-streaked,  as  is  usually 
that  of  croupous  pneumonia.  Croupous  pneumonia  terminates 
in  the  course  of  seven  or  nine  days  b3^  crisis ;  catarrhal  pneu- 
monia is  a  disease  of  long  duration,  with  tardy  convalescence. 
The  physical  signs  of  croupous  pneumonia  are  well-defined, 
usually  limited  to  one  lung  and  to  a  lower  lobe;  the  signs 
of  catarrhal  pneumonia  are  ill-defined  and  irregularly  dis- 
seminated. 

How  is  passive  or  hypostatic  congestion  of  the  lungs  to  be 
distinguished  from  pneumonia? 

Passive  or  hypostatic  congestion  of  the  lungs  may  develop  in 
the  course  of  acute  or  chronic  debilitating  diseases  or  as  a  re- 
sult of  heart-disease  ;  it  usually  affects  the  bases  and  most  de- 
pendent portions  of  the  lungs.  It  is  attended  with  increased 
frequency  of  breathing,  impaired  percussion-resonance,  and  the 
presence  of  tine  rales.  It  differs  from  pneumonia  in  its  associa- 
tion with  the  conditions  that  give  rise  to  it ;  in  the  absence  of 
fever,  unless  arising  in  the  course  of  a  febrile  disorder  ;  in  its 
bilateral  distribution  ;  in  the  absence  of  blowing  breathing  ;  in  its 
course  and  in  its  submission  to  appropriate  management.  If  ex- 
pectoration attend  congestion  of  the  lungs  it  is  not  hemorrhagic. 

How  is  pulmonary  infarction  to  be  distinguished  from  pneu- 
monia? 

Coagulation  of  the  circulating  blood  may  take  place  in  the 
right  side  of  the  heart  as  a  result  of  increased  coagulability  or 
of  retarded  circulation,  or  a  thrombus  may  form  in  a  distant 
vein,  and  detached  fragments  of  clot  be  swept  into  the  lungs. 
The  occurrence  is  attended  with  pain  in  the  chest,  dyspnea,  and 
blood-streaked  expectoration.  Small  areas  of  dulness  on  per- 
cussion can  be  detected,  with  enfeebled  or  bronchial  breathing. 
There  may  be  slight  fever,  from  secondary  inflammation.  The 
condition  differs  from  pneumonia  in  being  secondary  to  a  pre- 


ACUTE  CROUPOUS  PNEUMONIA.         181 

existent  condition,  in  the  circumscribed  distribution  of  the 
pliysical  phenomena  on  the  part  of  the  Umgs,  in  the  comparative 
absence  of  fever,  and  in  the  course  of  the  disease.  Pulmonary 
infarction  is  not  of  itself  fatal.  The  danger  is  from  the  condition 
of  which  the  infarction  is  but  one  result. 

How  is  pulmonary  infarction  to  be  distinguished  from  pul- 
monary abscess  ? 
Pulmonary  embolism  may  result  in  either  infarction  or  ab- 
scess. The  outcome  depends  upon  the  presence  or  absence 
of  pyogenic  microorganisms.  The  immediate  phenomena  are 
the  same  in  both  instances.  If  suppuration  take  place,  how- 
ever, there  are  repeated  chills,  decided  fever,  with  purulent 
expectoration.  Pulmonary  abscess  is  obviously  the  graver  con- 
dition. The  existence  of  disseminated  suppuration  is  an  aid  in 
the  diagnosis. 

How  is  pneumonia  to  be  discriminated  from  pulmonary  tuber- 
culosis ? 

Pneumonia  is  an  acute  disease,  terminating  by  crisis  in  from 
five  to  nine  days  ;  the  tendency  of  pulmonary  tuberculosis  is  to 
be  chronic  ;  its  duration  is  indefinite.  The  sputum  of  pneu- 
monia may  be  profusely  admixed  with  blood,  but  actual 
hemorrhage  does  not  occur  except  in  the  peculiar  form  of  pneu- 
monia associated  with  influenza.  Characteristic  diplococci  are 
present ;  while  tubercle-bacilli  are  found  when  pulmonary  tu- 
berculosis exists.  The  emaciation,  the  anemia  and  the  sweats 
of  pulmonary  tuberculosis  are  not  present  in  uncomplicated 
croupous  pneumonia.  The  temperature  of  tuberculosis  com- 
monly displays  wide  variations ;  the  temperature  of  pneumonia 
is  of  a  continued  type.  Tuberculosis  usually  involves  the  upper 
portion  of  the  lung,  successively  invading  the  remainder  of  the 
lung  and  the  opposite  lung  as  well ;  pneumonia  is  usually  un- 
ilateral and  situated  in  a  lower  lobe.  The  physical  signs  differ 
in  accordance  with  this  peculiarity  of  distribution.  So-called 
tuberculous  pneumonia  may  be  indistinguishable  from  the 
ordinary  type  of  croupous  pneumonia  until  tubercle-bacilli 
appear  in  the  sputum ;  it  may  be  suspected  if  diplococci  are 
absent. 


182  ESSENTIALS   OF   DIAGNOSIS. 


Pulmonary  Gangrene. 

What  are  the  clinical  features  of  pulmonary  gangrene  ? 

Gangrene  of  the  lung  may  result  in  the  course  of  puhnonary 
tuberculosis,  or  of  pneumonia  ;  it  may  depend  upon  ulcerative 
communication  of  the  lung  with  an  adjacent  septic  process  ;  it 
may  be  occasioned  by  the  inspiration  of  septic  matters  from 
some  portion  of  the  respiratory  tract ;  finally  it  may  have  its 
origin  in  a  septic  embolus.  The  symptom  characteristic  of 
pulmonary  gangrene  is  the  expectoration  of  a  horribly  offensive, 
stinking  sputum,  in  association  with  a  typhoid  condition.  Un- 
less cavitation  occurs,  the  physical  signs  are  obscure  ;  at  best, 
they  may  be  masked  by  those  of  the  primary  condition. 

How  is  pulmonary  gangrene  to  be  distinguished  from  pulmo- 
nary abscess  ? 

The  physical  signs  and  the  local  phenomena  of  pulmonary 
gangrene  and  of  pulmonary  abscess  may  be  similar  ;  but  the  ex- 
pectoration in  a  case  of  abscess  is  copious  and  purulent,  while 
that  of  a  case  of  gangrene  is  brownish  and  horribly  offensive  and 
more  likely  to  contain  fragments  of  pulmonary  structure.  The 
signs  of  a  cavity  are  more  likely  to  attend  abscess  than  to  attend 
gangrene.  Gangrene  is  more  nearly  certain  than  abscess  to  be 
fatal. 

How  are  pulmonary  tuberculosis  and  pulmonary  gangrene  to 
be  differentiated  ? 

Gangrene  may  complicate  tuberculosis  of  the  lung.  It  differs 
from  uncomplicated  tuberculosis  by  the  cliaracteristic  odor  of 
the  breath  and  sputum  and  the  absence  of  tubercle-bacilli  from 
the  matters  expectorated. 

Pulmonary  Tuberculosis. 

What  are  the  varieties  of  pulmonary  tuberculosis  ? 

In  the  present  state  of  knowledge  pulmonary  tuberculosis 
may,  for  practical  purjDOses,  be  considered  under  two  forms  : 
confluent  and  disseminated.     The  lesion  in  both  is  essentially  the 


PULMONARY    TUBERCULOSIS.  183 

same,  the  process  in  the  one  instance  having  a  tendency  to  lo- 
caUzation  and  chronicity,  with  slow  extension ;  in  the  other  to 
diffusion  and  acuteness.  In  both,  also,  the  process  may  be  acute 
or  chronic.  Acute  miliary  tuberculosis  is  rarely  a  pulmonary 
affection  alone,  but  most  frequently  involves  several  organs 
from  the  first,  and  is  comparable,  in  many  respects,  to  an  acute 
infectious  fever,  such  as  one  of  the  exanthemata.  Indeed, 
the  lungs  may  be  less  involved  than,  for  example,  the  intestines 
or  the  peritoneum.  Localized  tuberculosis  may  undergo  retro- 
gression and  cicatrization  by  fibroid  substitution,  sometimes 
associated  with  calcareous  deposits.  On  the  other  hand,  it  may 
terminate  by  softening  (cheesy  necrosis  or  caseation),  leading 
to  excavation  or  the  formation  of  vomicae.  Calcification,  how- 
ever, may  occur  even  after  caseation  has  taken  place. 

Galloping  consumption  or  florid  phthisis  is  either  an  extremely 
rapid  form  of  confluent  tuberculosis  of  the  lung  or  a  rapidly 
caseating  subacute  or  chronic  broncho-pneumonitis,  on  which 
tuberculosis  has  supervened. 

Fibroid  phthisis  is  a  slow,  localized  tuberculosis  in  which  cica- 
trization keeps  almost  even  pace  with  tuberculous  ulceration. 

The  fibroid  conditions  of  the  lungs  found  in  miners,  in  steel- 
grinders,  and  in  others  exposed  to  the  inhalation  of  fine  parti- 
cles of  dust,  will  be  considered  as  forms  of  interstitial  pneumo- 
nitis, comparable  to  interstitial  hepatitis  and  interstitial  ne- 
phritis. Tuberculosis  may  supervene,  running  then  the  ordi- 
nary course. 

What  are  the  symptoms  of  pulmonary  tuberculosis  ? 

The  course  of  ordinary  chronic  pulmonary  tuberculosis  may 
pathologically  be  divided  into  three  stages :  a  first  or  incipient 
stage,  in  which  the  formation  of  tubercles  begins  ;  isolated,  mili- 
ary nodules  are  localized  at  some  part  of  the  lung,  most  com- 
monly at  an  apex  ;  a  second  stage,  of  consolidation,  in  which  the 
formation  of  tubercles  has  increased  in  number  and  density,  but 
not  correspondingly  in  extent,  the  tendency  to  localization  con- 
tinuing ;  and  a  third  stage,  of  softening,  in  which,  as  a  result  of 
caseation  and  breaking  down  of  the  older  tuberculous  forma- 
tions, cavities  develop  ;  while  at  the  same  time  invasion  of  new 
areas  takes  place. 


184  ESSENTIALS    OF    DIAGNOSIS. 

The  physical  signs  in  the  different  stages  differ  in  accordance 
with  the  lesions.  The  symptoms  of  one  stage,  however,  pass  by- 
imperceptible  gradations  into  those  of  another,  and  it  must  be 
remembered  that  while  in  certain  portions  of  the  Imig  the  pro- 
cess may  have  reached  the  third  stage,  in  other  portions  tuber- 
culous infiltration  may  be  just  beginning. 

The  onset  of  the  disease  is  usually  insidious.  The  individual 
complains  of  a  sense  of  lassitude  and  of  an  unusual  readiness  of 
fatigue.  Exertion  induces  shortness  of  breath.  There  is  a 
gradual  failure  of  nutrition.  The  color  fades  ;  the  digestion  is 
deranged.  Perhaps  now  a  slight,  irritating  cough,  attended 
with  little  or  no  expectoration,  sets  in.  Sometimes,  however,  the 
first  symptoms  are  observed  after  a  neglected  "  cold,"  or  super- 
vene upon  an  attack  of  catarrhal  pneumonia  (so-called  caseous 
phthisis).  An  occasional  sense  of  chilliness  in  the  back  may  be 
perceived.  The  body-weight  diminishes.  Careful  observations 
may  detect  a  slight  rise  of  temperature  at  noon  or  within  an 
hour  afterward,  and  perhaps  again  toward  five  o'clock.  Perhaps 
at  this  time,  unprovoked,  the  patient  feels  a  tickling  in  the 
throat,  perceives  a  salty  taste,  and  before  he  realizes  what  is 
about  to  transpire  he  ejects  a  mouthful  of  bright-red,  frothy 
blood.  The  hemorrhage  may  be  repeated  ;  at  this  stage  it  is  not 
likely  to  be  fatal.  The  cough  becomes  more  aggravated  ;  it  oc- 
curs in  paroxysms,  the  severity  of  which  may  induce  vomiting, 
especially  on  rising  in  the  inorning.  The  sputum  is  abundant 
and  muco-purulent ;  it  contains  elastic  fibers  and  tubercle- 
bacilli.  The  dyspnea  has  become  decided.  Emaciation  pro- 
gresses ;  recognizable  evening  fever  appears ;  debilitating  night- 
sweats  occur.  Hemorrhages  become  more  common  and  more 
profuse.  The  cheek  is  flushed,  the  eye  bright,  the  intelligence 
quickened,  the  mind  hopeful.  The  hair  becomes  straight  and 
prematurely  gray.  Digestion  fails.  Diarrhea  becomes  trouble- 
some. Atrocious  pains  in  various  parts  of  the  chest  indicate  the 
existence  of  accompanying  pleuritic  processes.  The  ends  of  the 
fingers  become  enlarged  and  bulbous,  the  nails  incurvated.  The 
anemia  is  profound  ;  the  loiver  extremities  become  edematous. 
The  patient  must  take  to  his  bed.     In  the  last  stages  of  the 


PULMONARY   TUBERCULOSIS.  185 

disease,  the  patient  may  suddenly  be  seized  with  agonizing  pain 
in  the  side,  increased  dyspnea,  and  a  sense  of  impending  death. 
One  side  of  the  chest  becomes  enlarged  ;  the  percussion-reso- 
nance is  tympanitic  ;  the  breathing  is  but  feebly  transmitted  ; 
and  metallic  tinkling  may  be  developed.  Pneumothorax  has  oc- 
curred. 

Death  ultimately  results  from  exhaustion,  and  is  frequently 
preceded  by  the  supervention  of  disseminated  tuberculosis, 
giving  rise  to  the  febrile  and  toxemic  symptoms  of  that  condition. 
Occasionally  a  large  hemorrhage  brings  about  a  fatal  issue  by 
suffocation,  from  inspiration  of  a  portion  of  tbe  fluid. 

Pulmonary  tuberculosis  is  not  rarely  complicated  b}-  or  asso- 
ciated with  other  tuberculous  affections,  especially  larj^ngeal 
tuberculosis  and  intestinal  tuberculosis,  the  symptoms  of  which 
•are  then  superadded. 

What  are  the  physical  signs  of  the  first  stage  of  pulmonary 
tuberculosis  ? 

The  chest  may  be  full  and  symmetrical.  The  respiratory  excur- 
sion may  be  sufficient ;  perhaps,  by  standing  behind  the  patient 
and  placing  the  hands  on  the  front  of  his  chest,  a  slight  defi- 
ciency of  expansion  at  an  apex  may  be  detected.  The  j;erci6S- 
sion-resonance  is  vesicular,  except  over  a  small  area  at  the  upper- 
most portion  of  one  lung,  where  there  is  slight  relative 
impairment.  At  this  point,  too,  the  vesicular  murmur  is 
altered.  The  inspiratory  murmur  is  less  soft  and  breezy  than 
normal,  while  expiration  is  prolonged  and  heard  more  distinctly 
than  usual;  or  inspiration  is  jerking  and  arrhythmic.  Careful 
auscultation  by  an  acute  observer  may  detect  fine  moist  rales  at 
the  end  of  inspiration.  Vocal  resonance  and  fremitus  are  slightly 
increased.  If  there  is  any  expectoration,  careful  search  may 
detect  a  small  number  of  tubercle-bacilli  in  the  sputum.  With 
the  fluoroscojpe  a  faint  shadow  may  be  seen  to  replace  the  nor- 
mal pulmonar}'  transparency  in  the  affected  area,  and  this  may 
be  demonstrated  by  skiagraphy.  The  excursion  of  the  dia- 
phragm may  also  be  seen  with  the  fluoroscope  to  be  limited  on 
the  affected  side. 


186  ESSENTIALS    OF    DIAGNOSIS. 

What  are  the  physical  signs  of  the  second  stage  of  pulmonary 
tuberculosis  ? 
The  respiraimy  frequency  is  slightly  accelerated.  The  upper 
part  of  the  chest  is  less  full  on  one  side  than  on  the  other,  and 
the  expansion  in  this  area  is  deficient.  The  rcsonmice  here  is 
impaired  ;  the  percussion-note  may  be  dull.  The  vesicular  ele- 
ment of  the  respiratory  murmur  is  wanting.  Inspiration  is 
harsh  ;  expiration  is  prolonged  and  blowing  ;  the  breathing  may 
be  bronchial.  Fine  crackling  sounds  are  heard.  Vocal  reso- 
nance and  fremitus  are  notably  increased.  Blowing  sounds  may 
be  heard  on  stethoscopic  auscultation  over  the  subclavian  ves- 
sels. The  sputum  contains  many  bacilli.  Fluoroscopic  shadows 
are  marked. 

What  are  the  physical  signs  of  the  third  stage  of  pulmonary 
tuberculosis  ? 

The  general  emaciation  is  striking.  Decided  depressions  exist 
above  and  below  the  clavicle,  on  one  or  on  both  sides.  The 
ribs  are  prominent,  the  interspaces  narrowed.  The  chest  appears 
rigid  ;  it  may  heave,  but  it  scarcely  expands  in  respiration. 
The  percussion-dulness  is  marked,  perhaps  in  different  degree 
over  the  upper  lobes  of  the  tw^o  sides.  Here  and  there,  in  irreg- 
ular areas,  are  heard  the  dull  sounds  of  a  thickened  pleura.  In 
the  midst  of  the  dulness  a  tympanitic  or  amphoric  or  cracked-pot 
sound  is  elicited.  Coarse  and  fine  rales,  gurgling,  bronchial  or 
cavernous  breathing  are  heard.  Bronchophony  or  whispering 
pectoriloquy  is  present.  Tactile  fremitus  is  increased.  The 
sputum  contains  bacilli  and  elastic  fibers. 

What  are  the  best  methods   for  detecting  the  presence  of 
tubercle-bacilli  in  sputum? 

In  all  bacteriologic  investigations,  the  instruments  and 
appliances  used  must  be  rigidly  sterile.  Sputa  for  examination 
should  be  collected  in  glass  or  porcelain  vessels  that  have  been 
made  clean  by  boiling,  and  finally  washed  with  a  1  :  1000  solu- 
tion of  mercuric  chloride.  The  examination  should  not  be  too 
long  deferred.     In  the  interval  the  vessel  should  be  covered. 

The  sputum  should  be  poured  from  its  receptacle  on  a  steril- 
ized plate  of  glass  having  a  black  background.  With  a  plati- 
num wire,  first  heated   to  redness  in  the  flame  of  a  lamp  or 


PULMONARY  TUBERCULOSIS.  187 

Bunsen  burner  and  permitted  to  cool,  a  small  quantity  of 
purulent  matter  is  taken  up  and  spread  in  a  thin  layer  upon  a 
cover-glass  that  has  been  washed  with  alcohol,  ether,  and  bi- 
chloride solution  and  carefully  wiped  dry.  The  thin  layer  of 
sputum  is  permitted  to  dry  at  ordinary  temperature,  or  the  pro- 
cess is  accelerated  by  gentle  heat.  AVhen  perfectly  dry,  the 
cover-glass  preparation  is  drawn  three  or  four  times  through  the 
rtame  so  as  to  fix  the  albuminoid  matters. 

The  preparation  is  now  ready  to  be  stained.  For  the  staining, 
a  filtered  solution  composed  of  one  part  of  fuchsin  (or  gentian 
violet) ,  four  of  carbolic  acid,  ten  of  alcohol  and  one  hundred  of 
sterilized  distilled  water,  may  be  used  ;  or  ten  or  fifteen  drops 
of  anilin  oil  and  about  a  dram  of  sterilized  distilled  water  are 
shaken  together  and  filtered,  and  then  sufficient  of  a  saturated 
alcoholic  solution  of  gentian-violet  (or  fuchsin)  addded  until  a 
deep  coloration  is  produced. 

The  cover-glass  preparation  may  now  be  floated  on  the  sur- 
face of  one  of  the  solutions  indicated,  for  twenty-four  hours,  at 
the  ordinary  temperature,  or  the  process  may  be  accomplished  in 

Fig,  23, 


A- 


Tubercle-bacilli  in  sputum.    (Ziegler.) 

fifteen  minutes  by  the  application  of  moderate  heat  until  the 
vapor  of  steam  arises  ;  or  face  upward,  a  few  drops  of  either  of 
the  solutions  indicated  are  placed  upon  the  surface  of  the  cover- 
glass  preparation,  which  is  gently  heated  until  the  vapors  of 
steam  arise. 


188  ESSENTIALS    OF    DIAGNOSIS 

The  excess  of  free  stain  is  removed  with  water.  The  prep- 
aration is  decolorized  in  a  solution  of  nitric  acid  (1  :  3),  or  in 
one  of  sulphuric  acid  (1  :  4).  It  is  then  briedy  passed  through 
seventy  per  cent,  alcohol.  It  may  at  once  be  dried  and 
mounted  and  examined,  but  it  is  better  to  stain  again  with  an 
aqueous  solution  of  a  color  contrasting  with  that  first  used— 
fuchsin  and  methylene-blue,  gentian-violet  and  vesuvian  or 
Bism  arck-brown. 

The  search  for  bacilli  in  sputum  may  be  facilitated  by  adding 
to  about  four  ounces  of  sputum,  one  ounce  of  sterilized  distilled 
water,  and  from  four  to  eight  drops  of  liquor  sodse  and  heating  ; 
from  two  to  three  ounces  more  of  water  are  added  and  the 
mixture  is  put  aside  in  a  conical  glass  for  from  twenty-four  to 
forty-eight  hours,  when  the  supernatant  fluid  is  decanted  and 
cover-glass  preparations  made  from  the  sediment. 

Centrifugation  may  be  practised  when  bacilli  are  not  readily 
found  otherwise. 

What  is  the  clinical  course  of  "  galloping  consumption"  ? 

The  rapid  form  of  confluent  pulmonary  tuberculosis,  known 
as  "quick  consumption"  or  phthisis  florida^  as  distinguished 
from  the  infectious  fever  known  as  acute  miliary  tuberculosis, 
not  infrequently  supervenes  upon  a  neglected  "cold,"  com- 
monly a  catarrhal  pneumonia  of  the  apex  ;  or  it  may  suddenly 
become  manifest  after  localized  tuberculosis  of  the  apex,  so 
slight  as  to  be  unsuspected,  has  existed  for  a  longer  or  shorter 
time  ;  it  may  closely  or  remotely  follow  an  attack  of  influenza ; 
or  its  immediate  antecedents  may  be  untraceable.  Frequently, 
the  subjects  of  phthisis  florida  present  an  hereditary  liability  to 
tuberculosis.  Careful  inquiry  may  elicit  a  history  pointing  to 
tuberculous  infection  of  the  bronchial  glands  in  childhood,  -as 
shown  by  recurrent  attacks  of  cough  and  fever,  or  to  actual 
"  scrofulous  "  manifestations. 

Clinically  the  disease  is  marked  by  high  temperature  of  a 
continued  or,  more  frequently,  a  remittent  type  ;  profuse  night- 
sweats  ;  profound  digestive  and  circulatory  disturbance  ;  rapid 
wasting,  with  accompanying  weakness  ;  and  pulmonary  symp- 
toms of  progressive  severity,  AviLh  corresponding  physical  signs. 
Pathologically  it  is  characterized  by  rapid  caseation,  with  for- 


PULMONARY    TUBERCULOSIS.  189 

matiou  of  extensive  cavities ;  severe  laryngeal  and  intestinal 
complications  are  frequent.  It  may  apparently  begin  as  an 
acute  laryngitis  of  ordinary  or  of  tuberculous  type.  Sometimes 
persistent  diarrhea  is  the  earliest  symptom  to  attract  attention. 
The  duration  of  the  disease  is  from  a  few  weeks  to  about  eighteen 
months. 

How  is  a  pulmonary  hemorrhage  to  be  discriminated  from  a 
gastric  hemorrhage  ? 

The  blood  of  pulmonary  hemorrhage  has  a  sweetish  or  saltish 
taste,  is  usually  fluid,  bright-red,  alkaline  and  more  or  less 
frothy.  There  is  a  previous  history  or  evidence  of  disease  of 
the  lungs  or  heart.  The  expectoration  continues  blood-streaked 
for  several  days.  In  gastric  hemorrhage  the  blood  is  usually 
acid,  dark  and  clotted ;  its  taste  is  masked  as  a  result  of  ad- 
mixture with  the  contents  of  the  stomach ;  the  stools  that  fol- 
low are  tarry. 

Pulmonary  hemorrhage  may  occur  Avith  or  without  cough,  and 
is  not  provoked  hj  taking  food.  Gastric  hemorrhage  usually 
occurs  with  vomiting,  and  is  provoked  by  taking  food. 

How  is  the  distinction  to  be  made  between  pulmonary  tuber- 
culosis and  chronic  pleurisy  ? 
Pleural  adhesion  and  thickening  are  extremely  common. 
The}'  occasion  retraction  of  the  chest-wall,  often  more  or  less 
displacement  of  the  heart,  and  give  rise  to  dulness  on  percus- 
sion, enfeebled  transmission  of  the  breath-sounds  and  dimin- 
ished vocal  resonance  and  fremitus  ;  but  they  are  not  associated 
with  the  ascultatory  and  constitutional  phenomena  of  pulmo- 
nary tuberculosis,  or  with  the  presence  of  tubercle-bacilliin  the 
sputum.  If  a  pleural  effusion  is  present,  there  are  bulging  of 
the  lower  part  of  the  chest,  flatness  on  percussion,  feebleness 
or  absence  of  breath-sounds,  and  diminished  vocal  resonance  and 
fremitus.  If  the  fluid  is  purulent,  there  are  chills,  fever,  sweats 
and  emaciation. 

How  is  pulmonary  carcinoma  to  be  distinguished  from  pulmon- 
ary tuberculosis  ? 
Carcinoma  of  the  lung  is  more  commonly  secondary  than 


190  ESSENTIALS    OF    DIAGNOSIS. 

primary.  The  metastatic  growths  give  rise  to  irregularly  dis- 
tributed, multiple  areas  of  percussion-dulness,  without  corres- 
ponding change  in  the  auscultatory  phenomena.  The  tempera- 
ture is  likely  to  be  sub-normal  rather  than  febrile,  unless  in- 
flammation of  the  lung  or  pleura  is  excited.  The  duration  of 
pulmonary  carcinoma  is  limited ;  pulmonary  tuberculosis  may 
be  indefinitely  protracted.  Tubercle-bacilli  are  not  found  in 
the  sputum  in  pulmonary  carcinoma.  The  presence  of  car- 
cinomatous new-growths  elsewhere  is  significant  in  doubtful 
cases. 

How  is  pulmonary  syphilis  to  be  distinguished  from  pulmon- 
ary tuberculosis  ? 

Syphilis  of  the  lung  appears  either  in  the  form  of  gummata 
or  as  fibroid  induration.  It  is  to  be  distinguished  from  tuber- 
culosis by  the  absence  of  bacilli  from  the  sputum,  by  the  involve- 
ment of  the  middle  and  lower  parts  rather  than  the  upper  part  of 
the  lung,  by  the  diffuse  and  irregular  rather  than  concentrated 
locahzation  of  physical  signs,  by  the  absence  of  the  constitu- 
tional phenomena  of  tuberculosis,  and  by  the  history  or  the 
knowledge  of  the  existence  of  other  syphilitic  manifestations. 
The  therapeutic  test  is  sometimes  available,  but  should  be 
cautiously  applied,  as  cases  of  tuberculosis  are  usually  injured 
by  potassium  iodide. 

Syphilis  and  tuberculosis  may  coexist. 

How  are  bronchiectasis  and  pulmonary  tuberculosis  to  be  dif- 
ferentiated ? 

Bronchiectasis  is  attended  ■■•  with  copious  muco-purulent 
expectoration,  and  perhaps  with  decided  emaciation  ;  the  pul- 
monary resonance  may  be  impaired,  and  large,  moist  rales  may 
be  heard;  but  the  physical  phenomena  are  often  bilateral  in 
distribution  and  most  decided  at  the  bases  of  the  lungs ;  pulmo- 
nary tuberculosis  usually  begins  at  the  apex  of  one  lung,  whence 
it  extends.  When,  as  is  not  uncommonly  the  case,  bronchial 
dilatation  is  found  in  the  upper  portion  of  one  lung,  its  discrim- 
ination from  a  tuberculous  vomica  is  difficult,  and  must  be 
based  rather  on  the  results  of  microscopic  investigation  and  the 
general  phenomena  than  on  the  physical  signs.    Bronchiectasis 


ACUTE    MILIARY    TUBERCULOSIS.  191 

is  slowly  if  at  all  progressive;  tuberculosis  less  commonly  stops 
short  of  a  fatal  termination.  The  sputum  of  a  case  of  bronchi- 
ectasis does  not  contain  tubercle-bacilli. 

How  is  an  abscess  of  the  lung  to  be  diagnosticated  from  pul- 
monary tuberculosis  ? 

An  abscess  of  the  lung  may  develop  in  the  course  of  a  pneu- 
monia or  an  empyema,  as  a  result  of  traumatism,  or  it  may  con- 
stitute a  manifestation  of  a  general  pyemia.  It  is  to  be  distin- 
guished from  tuberculosis  by  a  knowledge  of  its  possible  origin, 
by  the  appearance  of  the  phenomena  in  a  lower  rather  than  in 
an  upper  lobe  and  upon  one  side  only.  The  condition  is  acute 
rather  than  chronic,  and  the  sputum  does  not  contain  tubercle- 
bacilli.     The  physical  phenomena  are  peculiarly  circumscribed. 

By  what  means  are  malarial  fever  and  pulmonary  tuberculosis 
to  be  differentiated  ? 
When  caseation  and  suppuration  are  taking  place  in  a  lung, 
the  temperature  is  high  in  the  evening,  declining  towards 
morning.  In  addition,  however,  there  are  persistent  dyspnea, 
increased  frequency  of  breathing,  cough,  expectoration  contain- 
ing tubercle-bacilli,  loss  of  flesh,  night-sweats,  dulness  on  per- 
cussion, and  mucous  rales  on  auscultation.  The  symptoms  last 
enumerated  are  wanting  in  intermittent  fever,  while  the  Plas- 
modia of  malaria  are  wanting  in  the  blood  in  pulmonary  tuber- 
culosis. Possible  mistakes  in  diagnosis  are  to  be  avoided  by  a 
physical  examination. 

Acute  Miliary  Tuberculosis. 

What  are  the  symptoms  of  acute  miliary  tuberculosis  ? 

Acute  miliary  tuberculosis  sets  in  insidiously.  The  victim 
may  be  a  member  of  a  tuberculous  family.  He  is  taken  ill  with 
slight  cough,  scanty  or  no  expectoration,  marked  dj^spnea,  ele- 
vation of  temperature,  rapidity  of  pulse,  delirium,  and  other 
symptoms  of  a  grave  intoxication.  Tuberculous  involvement 
of  the  bowel  will  cause  diarrhea  ;  of  the  cerebral  meninges,  the 
signs  of  meningitis.  The  course  of  the  disease  may  be  rapid 
or  protracted.     Death  may  take  place  from  exhaustion,  or,  in 


192  ESSENTIALS    OF    DIAGNOSIS. 

rarer  instances,   the  acute   symptoms   subside,   and  those  of 
chronic  tuberculosis  appear. 

What  are  the  physical  signs  of  acute  miliary  tuberculosis  ? 

The  pliysical  signs  of  acute  miliary  tuberculosis  of  tlie  lungs 
are  at  first  practically  those  of  an  acute  bronchitis  :  a  full  chest ; 
rapid  breathing;  harsh,  vesiculo-bronchial  respiratory  sounds; 
unaltered  percussion-resonance ;  unchanged  vocal  resonance  and 
fremitus.  The  formation  of  subpleural  tubercles  gives  rise  to  a 
peculiar  friction-fremitus  appreciable  on  palpation.  Later,  dul- 
ness  at  one  apex  or  at  both  apices,  or  just  below,  and  fine  crack- 
ling rales  are  heard ;  and  still  later,  evidences  of  caseation  are 
found  on  auscultation  and  percussion.  The  detection  of  tuber- 
cle-bacilli may  be  very  late.  Some  cases  early  develop  indica- 
tions of  apex-pneumonia. 

How  are  acute  miliary  tuberculosis  and  typhoid  fever  to  be 
distinguished  from  one  another? 

The  prostration  and  the  general  condition  are  much  alike  in 
both ;  but  in  acute  miliary  tuberculosis  the  epistaxis,  the  rose- 
spots,  the  characteristic  temperature-course,  urine-reaction 
and  blood-reaction,  and  the  peculiar  stools  of  typhoid  fever 
are  wanting.  The  temperature  of  typhoid  fever  pursues  a 
definite  course,  that  of  acute  miliary  tuberculosis  presents 
considerable  oscillations  on  the  same  day;  without  thera- 
peutic interference,  it  may  be  normal,  subnormal  and  very 
high.  Bronchitis  may  attend  typhoid  fever,  but  the  dyspnea 
is  never  so  marked  as  it  is  in  acute  miliary  tuberculosis.  The 
progress  of  the  case  determines  the  diagnosis.  Not  only  do 
the  marked  physicial  signs  of  destructive  change  in  the  lungs 
develop  in  the  one  disease  and  not  in  the  other,  but  typhoid 
fever  is  a  self-limited  disease  of  known  duration,  with  a  ten- 
dency to  recovery,  while  acute  miliary  tuberculosis  is  a  disease 
of  uncertain  duration,  and  sooner  or  later  almost  invariably 
fatal. 

Tubercle-bacilli  may  sometimes  be  discovered  in  the  sputum 
of  acute  miliary  tuberculosis,  in  the  blood  or  in  the  spleen. 

The  knowledge  of  previous  scrofulous  or  tuberculous  dis- 
ease in  the  patient,  or  a  family  history  of  scrofula  or  tuber- 


INTERSTITIAL    PNEUMONITIS.  193 

culosis,  should  excite  suspicion  of  acute  tuberculosis;  and  in 
suscc])tible  subjects  the  latter  disease  may  even  quickly  fol- 
low typhoid  fever. 

Interstitial  Pneumonitis. 

What  are  the  characteristics  of  interstitial  pneumonitis  ? 

As  a  result  of  the  irritation  occasioned  by  the  constant 
inhalation  of  fine  particles  of  dust  by  miners  and  grinders,  and 
others,  a  chronic  bronchitis  with  hyperplasia  of  the  interstitial 
pulmonary  tissue  develops.  The  two  layers  of  pleura  are  often 
adherent  and  thickened.  As  time  progresses,  contraction  takes 
place,  terminating  in  condensation  of  the  lung  and  dilatation 
of  the  bronchial  tubes.  Interstitial  pneumonitis  may  develop 
as  a  part  of  a  general  fibroid  degeneration,  it  may  follow  acute 
pneumonia  or  other  disease  of  the  lung ;  or  it  may  be  associated 
with  pleural  thickening. 

In  coal  miners  the  condition  is  known  as  anthracosis ;  in  iron- 
workers as  siderosis ;  in  grinders  as  chalicosis. 

What  are  the  symptoms  of  interstitial  pneumonitis  ? 

There  is  obstinate  cough  and  abundant  muco-purulent  expec- 
toration, which  sometimes  contains  particles  of  the  dust  inhaled. 
There  may  be  considerable  wasting  and  dyspnea. 

What  are  the  physical  signs  of  interstitial  pneumonitis  ? 

The  chest  is  diminished  in  size,  rather  flattened  anteriorly, 
from  retraction.  The  respiratory  excursion  is  small,  the  chest 
expanding  but  little  in  inspiration.  The  percussion-resonance  is 
impaired  over  a  large  area  of  pulmonary  surface.  The  breath- 
ing is  bronchial.  Large  moist  and  dry  rales  are  heard.  The 
vocal  resonance  and  fremitus  are  increased. 

How  does  interstitial  pneumonitis  differ  from  chronic  pleurisy? 

Interstitial  pneumonitis  and  chronic  adhesive  pleurisy  are 
allied  conditions  and  are  often  associated.  Occurring  alone 
the  former  is  wider  in  its  distribution  and  is  more  likely  than 
the  latter  to  be  bilateral.  Blowing  breathing,  rales,  cough  and 
expectoration  attend  the  pulmonary,  but  not  the  pleural,  con- 
dition. 

13 


194  ESSENTIALS   OE   DIAGNOSIS. 

Pulmonary  Emphysema. 

What  are  the  characteristics  of  pulmonary  emphysema? 

Pulmo7iary  emphysema  is  usually  a  result  of  long-continued  ex- 
cessive expiratory  effort  with  closed  glottis — as  in  protracted 
cough  or  in  the  habitual  blowing  of  wind  instruments.  It  is 
often  associated  with  chronic  bronchitis.  The  air-vesicles  be- 
come dilated  into  large  sacs,  and  the  bloodvessels  in  the  inter- 
lobular septa  are  obliterated.  The  increased  work  thrown  upon 
the  right  heart  in  turn  gives  rise  to  dilatation. 

Emphysema  manifests  itself  by  dyspnea,  expiratory  in  char- 
acter ;  shortness  of  breath,  aggravated  in  paroxysms,  and  at- 
tended with  distressing  cough  and  scanty  expectoration ;  and 
cyanosis.  The  cardiac  insufficiency  adds  to  the  dyspnea  and 
may  be  the  cause  of  dropsy. 

What  are  the  physical  sig^ns  of  emphysema  ? 

The  chest  is  large,  "  barrel-shaped  ;"  the  circumference  being 
increased  in  greater  degree  than  the  vertical  diameter.  The 
respiratory  excursion  is  slight  and  may  be  scarcely  visible  ;  al- 
though the  chest  may  rise  and  fall  as  a  whole,  the  ribs  being 
fixed  in  the  position  of  full  inspiration.  The  percussion-resonance 
is  heightened,  almost  tympanitic.  The  hreath-sounds  are  feeble, 
being  almost  continuous  and  without  intermission,  expiration 
being  prolonged  and  attended  with  a  succession  of  puffs.  The 
vocal  resonance  and  fremitus  are  diminished.  The  area  of  super- 
ficial cardiac  dulness  is  diminished,  but  deep  percussion  will 
reveal  enlargement  of  the  right  ventricle. 

How  is  emphysema  to  be  distinguished  from  pneumothorax  ? 

Pneumothorax  usually  results  from  the  breaking  through  the 
pleura  of  a  destructive  process  in  the  lung,  such  as  the  casea- 
tion and  suppuration  of  tuberculosis.  The  symptoms  to  which 
it  gives  rise  are  abrupt  in  onset  and  distressing  in  character. 
The  patient  perceives  a  sudden,  severe  pain  in  the  side,  and  is 
seized  with  great  dyspnea  and  a  sense  of  impending  death. 
The  chest  is  seen  to  be  enlarged,  the  breathing  rapid  and  shal- 
low, the  respiratory  excursion  small ;  the  percussion-resonance 
is  tympanitic  and  the  breath-sounds  are  feeble.    In  pneumo- 


PNEUMOTHORAX.  195 

thorax,  the  dilatation  of  the  chest  and  the  tympany  are,  however, 
unilateral ;  in  emphysema,  they  are  symmetrical.  In  pneumo- 
thorax, an  amphoric  blowing  sound  is  heard  on  inspiration,  and 
if  pleurisy  with  effusion  have  set  in,  metallic  tinkling,  succussion 
sounds  and  egophony  as  well.  The  recognition  of  a  condition 
that  may  give  rise  to  perforation  and  pneumothorax  aids  in  the 
diagnosis. 

How  is  emphysema  to  be  distinguished  from  a  pleural  effusion? 

An  effusion  into  the  pleura  may  take  place  in  the  course  of  a 
pleurisy,  or  as  a  result  of  disease  of  the  heart  or  kidne3^  Ad- 
jacent organs  are  displaced  in  proportion  to  the  quantity  of 
fluid  poured  out.  If  the  percussion-note  be  hyper-resonant  at 
the  upper  part  of  the  chest,  above  the  level  of  the  fluid,  it  is 
flat  below.  Pleuritic  effusions  are  usually  unilateral ;  when  the 
effusion  is  part  of  a  general  dropsy  it  is  usually  bilateral.  Em- 
physema is  rarely  unilateral.  In  emphysema,  the  breath-sounds 
are  everywhere  feebly  heard  ;  in  pleural  effusion  the  breathing 
may  be  puerile,  or  even  bronchial,  above  the  level  of  the  fluid, 
but  the  breath-sounds  are  not  well  heard  through  the  fluid.  Vocal 
resonance  and  fremitus  are  diminished  in  emphysema ;  a"bsent 
below  the  level  of  a  pleural  effusion.  If  the  effusion  becomes  puru- 
lent, rigors,  hectic  fever,  sweats  and  marked  emaciation  occur. 

Pneumothorax. 

What  are  the  clinical  features  of  pneumothorax  ? 

Pneumothorax  m.Ry  result  from  traumatism  that  causes  fracture 
of  a  rib  and  perforation  of  the  lung ;  from  a  perforating  wound 
of  the  chest;  from  the  rupture  of  an  emphysematous  pulmo- 
nary alveolus ;  from  communication  between  the  pleural  cavity 
and  an  adjacent  hollow  viscus;  from  the  softening  of  a  septic 
inforct  or  of  an  area  of  2:)neumonic  consolidation ;  from  the 
development  of  gas  in  the  pleural  cavity ;  but  the  most  com- 
mon cause  is  ulcerative  perforation  of  a  tuberculous  cavity  in 
the  lung.  The  condition  usually  sets  in  suddenly,  with  sharp 
pain  in  the  side,  intense  dyspnea  and  a  sense  of  great  oppres- 


196  ESSENTIALS    OF    DIAGNOSIS. 

sion.  The  breathing  is  hurried  and  shallow.  The  chest  on  the 
affected  side  becomes  bulging ;  the  percusmon-note  is  tympanitic; 
the  breath-sounds  are  enfeebled  or  distant,  perhaps  amphoric; 
as  fluid  is  poured  out,  metallic  tinkling  may  be  heard,  and  by 
shaking  the  patient,  with  the  ear  applied  to  his  chest,  a  succus- 
si on-sound  may  be  elicited ;  the  voice-sounds  and  mbraiions  are 
poorly  transmitted.  Voice  and  cough  assume  a  metallic  tone 
in  transmission,  and  a  peculiar  bell-like  resonance  is  given  the 
transmitted  percussion-note  when  metallic  plexor  and  plexi- 
meter  (two  coins)  are  used.  The  heart,  as  well  as  other  viscera, 
may  be  displaced. 

How  are   pneumothorax   and  diaphrag^matic   hernia  to  be 
differentiated  ? 

The  stomach  may  be  dragged  upwards  beneath  the  ribs  by  a 
contracting  lung,  or  the  stomach  or  the  large  intestine  may 
bulge  through  a  yielding  portion  of  the  diaphragm,  so  that 
there  may  be  unilateral  percussion-tympany,  with  displacement 
of  the  heart ;  vibrations  of  the  fluid  in  the  hollow  viscus  may  give 
rise  to  metallic  tinkling,  which,  however,  occurs  independently 
of  respiration  and  is  associated  with  rumbling  sounds  peculiar 
to  the  gastro-intestinal  tract.  The  interference  With  the  respi- 
ratory functions  that  results  is,  moreover,  not  only  acute  in  on- 
set, as  it  is  in  pneumothorax  (of  which  the  etiologic  elements  are 
wanting),  but  it  may  be  equally  sudden  in  disappearance.  Dia- 
phragmatic hernia  may  have  a  history  dating  from  birth  ;  it 
bodes  no  danger  unless  strangulation  occurs,  of  which  the  symp- 
toms are  characteristic.  The  outcome  of  pneumothorax  is  in 
the  nature  of  things  often  rapidly  fatal. 

How   are   pneumothorax   and    a    pulmonary   cavity  to   he 
differentiated  ? 

A  large  cavity  in  the  lung  may  yield,  a  tympanitic  percussion- 
sound,  amphoric  respiration,  metallic  rales  or  tinkling,  and  suc- 
cussion-souuds,  but  the  phenomena  are  usually  circumscribed  ; 
there  is  no  bulging,  no  acute  exacerbation  of  pain,  dyspnea 
and  oppression,  and  the  percussion-flatness  of  an  efiusion  into 
the  pleural  sac  is  wanting. 


ASTHMA.  197 

How  is  pneumothorax  to  "be  distinguished  from  a  pleural 
effusion? 
Pneumothorax  sets  in  suddenly,  with  acute  pain  and  dyspnea. 
A  pleural  effusion  usually  takes  place  insidiously.  Pleurisy 
with  effusion  usually  attends  pneumothorax,  so  that  the  signs  of 
both  may  be  present ;  but  when  the  pneumothorax  is  the 
primary  condition,  the  percussion-note  above  the  level  of  the 
effusion  is  more  pronouncedly  tympanitic  and  the  voice  more 
distinctly  egophonic.  Succussion-phenomena  and  tinkling  are 
not  heard  unless  both  air  and  fluid  are  present  in  the  pleural 
sac.  Finally,  the  recognition  of  a  condition  that  gives  rise  to 
pneumothorax  may  decide  the  diagnosis. 

How  are  pneumothorax  and  subphrenic  abscess  to  be  differ- 
entiated ? 
Sometimes  an  accumulation  of  pus  and  gas  takes  place  be- 
neath the  diaphragm  in  the  sequence  of  perforation  of  the 
stomach  or  bow-el.  It  may  occur  on  either  side  and  give  rise 
to  symptoms  closely  resembling  those  of  pneumothorax.  The 
differentiation  will  depend  essentially  upon  a  knowledge  of  the 
previous  existence  of  disease  of  the  lung  on  the  one  hand  or 
of  the  stomach  or  bowel  on  the  other. 

Asthma. 

What  are  the  symptoms  of  asthma  ? 

Asthma  is  a  paroxysmal  affection,  the  symptoms  of  which 
may  be  dependent  upon  spasmodic  narrowing  or  exudative  in- 
flammation of  the  smaller  bronchial  tubes,  turgescence  of  the 
bronchial  vessels  or  an  urticaria-like  affection  of  the  bronchial 
mucous  membrane.  It  is  predisposed  to  by  a  neurotic  state. 
The  attacks  recur  at  irregular  intervals,  wdth  or  without  ap- 
parent exciting  cause.  Among  provocative  conditions  are 
changes  of  climate  and  weather,  overeating,  indigestion,  ema- 
nations from  various  sources,  possibly  reflex  disturbances  and 
sexual  excitement. 

The  seizure  is  sudden  in  onset,  usually  occurring  at  night.  The 
patient  is  awakened  with  a  sense  of  oppression  and  distressing 
dyspnea,  inspiratory  in  character.    Orthopnea  is  common.    Dur- 


198  ESSENTIALS    OF    DIAGNOSIS. 

ing  the  paroxysm,  which  may  last  for  several  hours,  the  chest 
heaves  spasmodically,  but  t\\Q,  imlmonavy  expansion  is  slight ;  the 
face  is  pale  or  livid,  and  the  distress  is  evident.  Loud,  wheezing 
sounds  are  heard.  On  auscultation,  the  hreath-somids  are  feeble, 
or  the  vesicular  murmur  may  be  obscured  by  the  wheezing  or 
replaced  by  sonorous  and  sibilant  rales.  The  percutory  ^jheno- 
mena  are  unaltered.  The  crisis  takes  place  with  a  profuse  ex- 
pectoration of  mucus,  perhaps,  also,  with  a  copious  discharge  of 
limpid  urine.  This  may  terminate  the  attack,  or  the  same  phe- 
nomena may  be  repeated  on  several  successive  nights  or  even  in- 
vade the  day.  The  sputum  consists  of  thin  mucus,  and  round 
gelatinous  masses,  which  are  found,  microscopically,  to  have  a 
spiral  arrangement.  Pointed  octahedral  cystals  also  are  present. 
The  number  of  esinophilous  blood-corpuscles  is  increased. 

Asthma  may  be  primary  or  secondary.  It  may  result  from 
reflex  influences,  such  as  disease  of  the  nose.  It  may  apparently 
replace  the  convulsive  seizure  of  epilepsy.  Asthmatoid  seizures 
are  common  accompaniments  of  chronic  bronchitis  and  emphy- 
sema, of  cardiac  insufficiency,  and  of  chronic  nephritis. 

How  is  asthma  to  be  distinguished  from  an  asthmatoid  con- 
dition ? 

In  true  asthma,  no  cause  for  the  disease  may  be  found  or  else 
some  local  or  reflex  irritation  may  be  discovered.  When  so- 
called  asthmatoid  attacks  occur,  their  discrimination  depends 
upon  the  recognition  of  an  organic  pulmonary  affection,  such 
as  emphysema  or  bronchitis,  or  of  cardiac  incompetency  or  of 
chronic  nephritis.  Such  attacks  do  not  pursue  the  typical 
course  of  true  asthmatic  seizures  and  do  not  terminate  suddenly 
with  profuse  expectoratioUo 

How  does  asthma  differ  from  whooping-cough  ? 

Whooping-cough  is  a  disease  of  children  ;  asthma,  a  disease 
of  adults.     The  characteristic  whoop  of  pertussis  is  wanting  in  , 
asthma.     An  attack  of  whooping-cough  does  not  last  more  than 
a  couple  of  months,  at  most ;  asthma  may  continue  indefinitely. 

What  are  the  points  of  differentiation  between  asthma  and 
paralysis  of  the  diaphragm  ? 
The  dyspnea  resulting  from  paralysis  of  the  diaphragm  is  not 


THE    DIGESTIVE    SYSTEiM THE    MOUTH.  199 

paroxysmal,  as  is  that  of  asthma.  Paralysis  of  the  diaphragm 
is  not  characterized  by  an  absence  of  the  breath-sounds,  followed 
by  wheezing  and  high-pitched  rales.  When  the  diaphragm 
is  paralyzed,  inspiration  is  attended  with  expansion  of  the 
chest  and  depression  of  the  abdominal  wall ;  in  expiration  the 
chest  collapses  and  the  abdominal  wall  is  elevated  ;  stimulation 
of  the  phrenic  nerves  restores  the  normal  harmony  of  action  ; 
attempts  at  bearing  down  are  futile  or  ineffective. 


New-growths  in  the  Lungs. 

What  are  the  clinical  features  of  new-growths  in  the  lungs  ? 

New-growths  in  the  lungs  are  usually  secondary,  rarely  primary. 
The  most  common  varieties  are  epithelioma,  encephaloid  and 
scirrhus.  Sarcoma  is  less  common.  Primary  carcinoma  usually 
involves  one  lung  only,  secondary  growths  both.  Among  the 
principal  symptoms  are  pain,  dyspnea,  cough  and  prune-juice 
expectoration.  There  may  be  also  cyanosis,  edema  and  dilata- 
tion of  the  veins  from  pressure.  The  percussion-resonance  is 
impaired  or  lost,  the  breathing  enfeebled,  possibly  bronchial ; 
vocal  resonance  and  fremitus  are  diminished.  External  lymph- 
atic glands  may  be  enlarged.  Sometimes  there  is  elevation  of 
temperature.     Emaciation  is  moderate. 


THE  DIGESTIVE  SYSTEM-THE  MOUTH. 

Catarrhal   Stomatitis. 

What  are  the  clinical  characteristics  of  catarrhal  stomatitis  ? 

Catarrhal  inflammation  of  the  mucous  membrane  of  the  mouth 
may  result  from  the  ingestion  of  irritating  substances,  from  the 
presence  of  carious  teeth,  or  by  extension  from  adjacent  dis- 
ease ;  it  may  also  develop  in  conjunction  with  morbid  dentition, 
or  derangement  of  digestion,  or  in  the  course  of  the  exanthe- 
mata. It  manifests  itself  by  redness,  tumidity,  and  increased 
heat  of  the  structures  within  the  mouth,  and  b}-  increased 
secretion.     Tlie  taking  of  food  is  attended  with  discomfort  or 


200  ESSENTIALS    OF    DIAGNOSIS. 

with  pain  ;  taste  is  impaired  ;  and  the  breath  is  offensive.    As  a 
rule,  there  is  httle  or  no  constitutional  disturbance. 

Aphthous  Stomatitis. 

What  are  the  clinical  features  of  aphthous  stomatitis  ? 

In  individuals  exposed  to  unfavorable  hygienic  conditions, 
and  in  those  debilitated  by  disease,  small  vesicles,  surrounded 
by  reddened  areolae,  appear  and  rupture,  leaving  ulcers  with 
grayish  bases  at  various  parts  of  the  mucous  membrane  of  the 
mouth.  Mastication  in  adults  and  nursing  in  infants  are  diffi- 
cult and  painful ;  the  secretions  of  the  mouth  are  increased ; 
the  appetite  may  be  impaired ;  digestion  may  be  deranged ; 
and  there  may  be  diarrhea. 

Thrush. 

What  are  the  clinical  manifestations  of  thrush  ? 

Thrush^  muguet  or  parasitic  stomatitis  is  a  mycotic  inflamma- 
tion of  the  mucous  membrane  of  the  mouth  and  throat,  to 
which  children  are  especially  prone.  It  is  dependent  upon  the 
presence  of  a  fungus,  termed  the  mycoderjna  (or  didiiim)  albicans. 
An  acid  reaction  of  the  secretions  of  the  mouth  is  an  essential 
condition  for  the  development  of  the  affection.  The  growth  of 
the  fungus  and  the  resulting  irritation  give  rise  to  the  formation 
of  minute  curd-like  masses  upon  various  parts  of  the  mucous 
membrane.  Forcible  detachment  of  the  masses  occasions  bleed- 
ing. The  symptoms  are  those  of  the  ordinary  form  of  stomatitis, 
plus  the  flaky  deposits  containing  the  characteristic  fungus. 
There  may  also  be  diarrhea  and  a  varying  degree  of  constitu- 
tional disturbance.  In  nurslings,  the  inability  to  suckle  may 
result  in  inanition  and  death. 

Ulcerative  Stomatitis. 

What  are  the  symptoms  of  ulcerative  stomatitis  ? 

Ulcerative  stomatitis  is  an  aggravated  form  of  inflammation  of 
the   mouth,   attended  with  ulceration,  which   it   is  stated  is 


GANGRENOUS    STOMATITIS  —  NOMA.  201 

usually  unilateral.  The  aftection  arises  amid  conditions  of 
crowding  and  filth,  and  in  those  supplied  with  insufficient  and 
inappropriate  food  ;  it  may  also  be  a  sequel  of  other  forms  of 
stomatitis,  of  caries  of  the  teeth,  or  of  the  maxillary  bones. 
It  is  manifested  by  impaired  appetite,  fetid  breath,  increased 
salivation,  pain  in  eating,  and  constitutional  symptoms  of 
varying  intensity.  Sometimes  adjacent  lymphatic  glands  under- 
go enlargement. 


Mercurial  Stomatitis. 

What  are  the  clinical  manifestations  of  mercurial  stomatitis  ? 

Stomatitis  sometimes  results  from  the  medicinal  ingestion  of 
large  quantities  of  mercury^  or  of  small  quantities  by  persons 
possessing  an  idiosyncrasy,  or  as  a  manifestation  of  mercurial 
intoxication  by  means  of  articles  of  food  or  drink,  or  from  ex- 
posure to  the  metal  in  certain  occupations.  The  sym^jtoms  vary 
greatly  in  severit3^  The  gums  especially  become  swollen,  red- 
dened, tender,  and  sometimes  ulcerated.  The  teeth  may  fall  out, 
and  the  maxillary  bones  become  carious.  The  breath  is  fetid.  The 
saliva  contains  mercury  ;  its  secretion  and  discharge  are  inordi- 
nately increased,  giving  rise  to  the  term  "salivation,"  as 
descriptive  of  the  affection. 

Gangrenous  Stomatitis — Noma. 

What  are  the  clinical  features  of  gangrenous  stomatitis  ? 

Gangrenous  stomatitis^  noma  or  cancrum  oris  is  essentially  an 
affection  of  childhood,  rare,  and  almost  invariably  fatal,  which 
develops  in  those  of  depraved  constitution,  often  at  the  termina- 
tion of  one  of  the  exanthemata,  particularly  measles.  It  is 
probably  of  bacterial  origin.  The  disorder  is  manifested  by  a 
brawny  induration  of  one  cheek,  the  structures  of  which 
undergo  disintegration,  with  resulting  ulceration  of  the  mucous 
and  cutaneous  surfaces,  and,  not  rarely,  perforation.  Adjacent 
portions  of  the  gums  may  by  contiguity  become  involved  in  the 
process.     The  teeth  may  fall  out  and  the  maxillary  bones  be- 


202  ESSENTIALS    OF    DIAGNOSIS. 

come  carious.  The  early  symptoms  may  be  obscured  by  those 
of  the  antecedent  condition.  Soon,  however,  the  breath  be- 
comes fetid,  and,  in  addition  to  the  local  manifestations,  the 
symptoms  of  septic  intoxication  may  appear,  in  the  midst  of 
which  the  child  may  die.  Recovery  may  take  place,  with  hide- 
ous deformity  of  the  face.  Pneumonia,  pulmonary  gangrene, 
and  entero-colitis  may  be  complications. 


THE  TONGUE. 

Glossitis. 

What  are  the  symptoms  of  glossitis  ? 

When  the  tongue  is  inflamed,  from  whatever  cause,  the  organ 
becomes  enlarged,  tumid,  reddened,  painful;  speech,  degluti- 
tion and  mastication,  sometimes  respiration,  are  interfered 
with,  and  the  secretions  of  the  mouth  are  increased.  The 
swelling  may  be  so  great  that  suffocation  results,  unless  relief 
be  given  by  incision.  Glossitis  may  be  superficial  or  parenchy- 
matous^ acute  or  chronic;  the  intensity  and  character  of  the  symp- 
toms being  modified  accordingly.  It  may  be  due  to  erysipelas, 
either  primarily  or  secondarily.  Epidemics  of  erysipelatous 
glossitis  have  occurred,  and  the  name." black  tongue"  has  been 
applied  to  this  affection.  Parenchymatous  glossitis  sometimes 
proceeds  to  suppuration. 


Leukoplakia  Lingualis. 

What  is  leukoplakia  of  the  tongue  ? 

Leukoplakia  lingualis^  or  leukoplakia  huccalis^  is  a  name  applied 
to  a  peculiar  chronic  affection  of  the  tongue  or  of  the  tongue 
and  buccal  mucous  membrane,  characterized  by  the  formation 
of  persistent,  horn}',  whitish  patches  upon  the  surface,  some- 
times extending  entirely  through  the  epithelial  layer.  Untreated, 
it  is  said  to  lead  at  times  to  the  development  of  carcinoma. 
Sometimes  it  appears  to  be  related  with  gout.  Syphilis,  tobacco 
and  alcohol  are  also  enumerated  among  its  causes. 


GEOGRAPHICAL   TONGUE  —  NiGRITiES.  203 


Geographical  Tongue. 

What  is  g-eographical  tong^ue  ? 

This  is  a  disorder  characterized  by  desquamation  of  the  su- 
periicial  epitheUum  of  the  tongue  in  circular  patches  that  ex- 
tend from  the  periphery.  It  is  attended  with  a  sense  of  itching 
and  heat.  It  has  been  observed  in  association  with  digestive 
derangement  and  it  has  been  considered  of  gouty  origin.  Re- 
lapse or  recurrence  is  common. 


Glossanthrax. 

What  is  glossanthrax  ? 

Glossanthrax  is  a  term  applied  to  tlie  localization  of  malignant 
pustule  upon  the  tongue.  It  is  to  be  differentiated  from  carci- 
noma, tuberculosis,  syphilis  and  other  affections  leading  to 
suppuration  or  ulceration.  The  local  and  constitutional  symp- 
toms are  those  of  anthrax  in  general.  The  appearance  of  the 
eschar  is  characteristic  and  the  presence  of  anthrax-bacilli  is 
diagnostic. 

Nigrities. 

What  is  nigrities  ? 

Nigrities,  also  called  black  tongue  and  hairy  tongue^  is  an  afiec- 
tion  of  the  filiform  papilite  of  the  tongue,  supposed  to  be  due  to 
the  irritation  of  a  special  fungus.  The  papillae  in  various  situa- 
tions become  discolored,  thickened,  and  elongated,  giving  the 
appearance  of  a  scattered  or  compact  hairy  growth  upon  the 
dorsum  of  the  tongue.  Desquamation  takes  place,  after  which 
the  tongue  may  remain  comparatively  clean  for  a  longer  or 
shorter  period ;  then  tlie  growth  recurs.  The  teeth  also  may  be 
black.  The  affection  is  to  be  differentiated  from  staining  of  the 
tongue  by  tobacco,  medicines,  and  the  like. 


204  ESSENTIALS   OF    DIAGNOSIS, 


MUMPS— PAROTIDITIS. 

What  are  the  symptoms  of  parotiditis  ? 

Parotiditis  or  mumps  may  be  primary,  or  secondary  in  the 
course  of  infectious  diseases.  It  may  be  epidemic  or  endemic. 
It  is  characterized  by  pain  at  the  angle  of  the  jaw,  followed  by 
tumefaction  of  the  parotid  gland,  at  first  on  one  side  and  then 
on  the  other.  Movement  of  the  jaw,  as  in  mastication,  is 
difficult  and  painful.  Deglutition  is  not  interfered  with  ;  hear- 
ing may  be  deranged.  The  secretion  of  saliva  is  usually  exces- 
sive ;  it  may  be  diminished.  There  are  febrile  manifestations 
of  moderate  severity.  The  period  of  incubation  is  from  fourteen 
to  twenty-five  days.  The  duration  of  the  disease  is  from  seven 
to  ten  days. 

Orchitis  or  ovaritis  is  a  peculiar  complication  of  parotiditis. 
It  is  likely  to  occur  as  the  parotid  swelling  subsides. 

THE  PHARYNX. 

Pharyngitis. 

What  are  the  symptoms  of  pharyngitis  ? 

In  aciite  catarrhal  pharyngitis^  or  angina,  the  symptoms  vary 
with  the  intensity  and  extent  of  involvement.  Ordinarily,  there 
are  "sore  throat,"  irritable  cough,  pain  or  difficulty  in  deglu- 
tition, interference  with  respiration,  enlargement  of  the  tonsils 
and  of  the  glands  of  the  neck.  On  inspection,  the  soft  palate,  the 
uvula,  the  tonsils,  the  posterior  and  lateral  walls  of  the  pharynx, 
or  the  palatine  arches  may,  one  or  more,  be  seen  to  be  reddened 
and  tumefied,  and  often  coated  with  glairy  mucus.  A  moderate 
degree  of  fever  attends  acute  pharyngitis. 

Acute  xMegraonous  pharyngitis  is  a  much  more  serious  affection, 
involving  not  only  the  mucous  membrane,  but  also  the  sub- 
mucous connective  tissues  and  even  at  times  the  sheaths  of  the 
muscles.  The  constitutional  symptoms  are  in  accordance  with 
the  severity  of  the  process,  and  may  be  those  of  pyemia.  The 
pus  may  gravitate  to  the  cellular  tissues  of  the  neck,  manifesting 


PHARYNGITIS.  205 

as  an  external  swelling  and  causing  dyspnea  or  even  suffocation 
from  compression  of  the  trachea.  The  inflamed  tissues  of  the 
throat,  especially  the  soft  palate  and  uvula,  may  be  greatly 
swollen  and  edematous. 

Chronic  pharyngitis  may  be  a  sequel  of  repeated  acute  attacks. 
It  is  common  in  those  who  smoke,  or  drink  alcohol  excessively, 
or  use  their  voices  a  good  deal.  The  pharj-nx  presents  a  gran- 
ular and  sometimes  a  glazed  appearance.  There  is  increased 
secretion  of  tenacious,  adherent  mucus. 

What  is  acute  tuberculous  pharyngitis  ? 

Acute  tuberculous  pharyngitis  is  a  form  of  acute  miliary  tuber- 
culosis, apparently  beginning  in  the  pharynx. 

The  constitutional  manifestations  are  those  of  an  acute  febrile 
process  of  grave  type,  sometimes  simulating  typhoid  fever. 

Locally,  deposits  of  tubercle  may  be  observed  beneath  the 
mucous  membrane  as  little  semi-transparent,  grayish  nodules, 
resembling  in  size  and  form  vermicelli-seeds  or  fish-eggs.  These 
are  collected  into  little  patches  more  or  less  confluent,  which 
eventually  undergo  ulceration. 

The  uvula  is  sometimes  thickened  into  a  somewhat  character- 
istic gelatinous-looking,  reddened,  club-shaped  mass.  This  ge- 
latinous thickening  may  likewise  take  place  in  other  portions 
of  the  pharynx. 

The  disease  may  extend  to  the  epiglottis,  tongue,  and  larynx, 
or  to  the  vault  of  the  pharynx  and  the  nasal  passages. 

The  ulcerative  process  usually  begins  on  a  palatine  fold  or 
on  a  lateral  wall  of  the  pharynx,  whence  it  rapidly  extends. 
Ulceration  may  penetrate  the  submucous  tissues,  and  the 
muscles  may  undergo  tuberculous  or  fatty  degeneration.  Pus 
is  usually  absent  from  the  surface  of  the  ulcers  and  the  bacillus 
tuberculosis  is  sometimes  found  in  the  detritus. 

The  chief  and  most  distinctive  local  subjective  sympAom  is  in- 
tense pain  in  swallowing,  often  more  than  can  be  accounted  for 
by  the  extent  of  visible  disease.  The  pain  may  extend  into  the 
ears. 

As  the  disease  progresses,  cough  is  superadded,  emaciation 
becomes  rapid,  and  signs  of  pulmonary  disease,  and  perhaps  of 
other  complications,  become  manifest. 


206  ESSENTIALS    OF    DIAGNOSIS. 

Death  may  result  within  a  few  weeks,  and  is  rarely  postponed 
beyond  two  or  three  months. 
liecovery  is  the  exception. 

How  is  tuberculous  pharyngitis  to  be  distinguished  from 
syphilitic  sore-throat  ? 

The  intense  pain  in  swallowing,  the  characteristic  deposit  and 
gelatinous  infiltration,  the  absence  of  pus  from  the  ulcers,  the 
histor}^  of  the  attack,  the  personal  history,  the  family  history  of 
the  patient,  and  the  febrile  symptoms  ;  the  discovery  of  the 
tubercle-bacillus  in  the  detritus  of  the  ulcers,  or  in  the  sputum, 
together  with  the  detection  of  the  evidence  of  pulmonary  tuber- 
culosis as  the  case  proceeds,  are  the  points  upon  which  the  diag- 
nosis from  syphilis  must  depend. 

Syphilitic  and  tuberculous  disease  may,  however,  coexist. 

The  supervention  of  t}'phoid  symptoms  in  a  case  of  supposed 
syphilitic  ulceration  of  the  throat  should  excite  suspicion  of 
the  existence  of  tuberculosis. 

How  is  tuberculous  pharyngitis  to  be  distinguished  from  typhoid 
fever  ? 
Typhoid  fever  is  sometimes  accompanied  by  ulcerative  phar- 
yngitis and  laryngitis,  though  the  cases  in  which  this  occurs  are 
much  rarer  in  North  America  than  tliey  appear  to  be  in  Europe. 
The  characteristic  fish-egg-looking  infiltration  of  tuberculosis 
and  the  non-purulent  character  of  the  ulceration  would  make 
the  discrimination  locally  ;  while,  constitutionally,  there  would 
be  absence  of  the  characteristic  temperature-course  and  blood- 
reaction,  of  the  rose-spots,  and  of  the  peculiar  stools  of  typhoid 
fever.     Discovery  of  the  tubercle-bacillus  would  be  conclusive. 

Tonsillitis. 

What  are  the  symptoms  of  tonsillitis  ? 

When  the  tonsils  are  inflamed,  adjacent  parts  usually  partici- 
pate in  the  process.  Parenchymatous  tonsillitis  or  quinsy  may  be 
primary  or  secondary  to  various  infectious  diseases.  It  sometimes 
sets'  in  suddenly,  with  a  chill,  followed  by  decided  elevation  of 
temperature  and  other  febrile  manifestations.  Usually,  one  tonsil 
only  is  afiected,  or  first  one  and  then  the  other,  but  bilateral  in- 
volvement may  occur  and  the  glands  become  so  intensely  swollen 


TONSILLITIS.  207 

as  to  meet  in  the  middle  line,  practically  obstructing  deglutition 
and  respiration.  In  such  cases  the  voice  is  nasal,  and  tluids  at- 
tempted to  be  swallowed  may  return  through  the  nose.  There 
is  always  some  interference  with  swallowing.  The  pain  is 
atrocious,  and  may  extend  into  the  ear  on  the  affected  side. 
There  is  increased  secretion  of  saliva ;  swallowing  is  increased 
in  frequenc}^  and  aggravates  the  pain.  Sometimes  the  patient 
lies  with  open  mouth,  making  labored  and  noisy  efforts  at  respi- 
ration, while  the  saliva  dribbles.  On  examination,  the  tonsils 
are  seen  to  be  enlarged  and  angry,  adjacent  parts  in  some  degree 
participating  in  the  inflammatory  process. 

The  enlargement  of  the  glands  can,  sometimes,  be  distinctly 
detected  from  without.  Tenderness  on  pressure  beneath  the 
angle  of  the  jaw  is  common. 

An  inflamed  tonsil  or  the  peritonsillar  tissues  may  suppurate, 
and  grave  complications,  such  as  ulceration  into  the  carotid 
artery  and  suffocation  from  rupture  into  the  larynx,  have 
occurred. 

Lacunal  or  follicular  tonsillitis  is  a  much  less  serious  affection. 
It  may  follow  exposure  to  cold  or  w^et,  or  it  may  arise  amid 
unhygienic  surroundings.  The  process  is  superficial,  the  lining 
membrane  of  the  lacunae  or  ducts  being  involved  rather  than 
the  substance  of  the  gland.  Scattered  over  the  surface  of  the 
inflamed  and  enlarged  tonsils  are  a  number  of  yellowish  points 
or  patches,  indicative  of  accumulations  of  sebaceous  matter, 
desquamated  epithelium  and  fungi,  at  the  orifices  of  the  ducts. 
These  plugs  may  be  readily  removed  by  means  of  a  scoop, 
sometimes  by  syringing — a  point  of  some  importance  in  the 
discrimination  from  diphtheria.  The  streptococcus  is  the 
microorganism  found  most  commonly  in  the  secretion.  Paren- 
chymatous tonsillitis  sometimes  follows  lacunal  tonsilitis,  and 
tonsillar  or  peritonsillar  abscess  may  then  develop.  Untreated, 
the  duration  of  tonsillitis  is  from  two  to  ten  days  or  more. 

Some  cases  of  tonsillitis  are  associated  with  pain  and  other 
rheumatic  manifestations  in  the  muscles  or  joints,  and  endo- 
carditis and  pericarditis  have  been  noted.  An  endocardial 
murmur  is  not  uncommon.  Swelling  of  the  joints  may  appear 
in  apparent  metastasis  as  a  tonsillar  inflammation  declines. 


208  ESSENTIALS    OF    DIAGNOSIS. 

Anomalous  eruptions  and  albuminuria  are  among  the  less 
common  concomitants  of  tonsillitis.  Paralyses  are  very  rare 
sequelae. 

Chronic  tonsillitis  is  most  common  in  young  persons  and  is 
characterized  by  hyperplasia,  causing  obstruction  of  the  phar- 
ynx, with  inability  to  breathe  through  the  nares,  in  consequence 
of  which  there  result  deformities  of  the  chest,  changes  in  facial 
expression,  mental  impairment  and  bodily  stunting.  Asthma- 
toid  seizures  may  occur  by  day,  and  snoring,  with  "  terrors  "  at 
night.  The  breath  is  fetid.  There  are  also  headache,  altered 
nasal  voice,  imperfect  articulation  ;  and  hearing,  taste  and  smell 
may  be  impaired.  Similar  conditions  may  attend  hyperplasia 
of  the  adenoid  tissues  of  the  vault  of  the  pharynx,  the  so-called 
pharyngeal  tonsil. 

Herpetic  Sore-Throat. 

What  is  herpetic  sore-throat  ? 

Herpetic  sore-throat,  herpetic  tonsillitis,  herpes  of  the  pharynx, 
common  membranous  sore-throat,  ulcer o-memhranous  angina,  diph- 
theroid throat,  are  names  applied  to  a  disease  often  mistaken  for 
diphtheria,  but  which  is,  in  reality,  a  form  of  inflammation  of 
the  mucous  membrane  of  the  palate,  tonsils,  uvula  and  pharynx, 
characterized  by  the  eruption  of  herpetic  vesicles,  which  soon 
rupture,  leaving  little  circular  ulcers  that  coalesce  and  become 
covered  with  a  fibrinous  exudation.  It  is  sometimes  associated 
with  herpes  of  the  lips. 

Constitutional  symptoms  maybe  absent,  but,  when  present,  are 
usually  of  a  mild  febrile  type.  There  may,  however,  be  high 
fever,  preceded  by  malaise  or  chill. 

The  pain  in  deglutition  (odynphagia),  and  the  dryness  and 
heat  of  the  throat  are  often  much  greater  than  in  ordinary 
forms  of  pharyngitis.  In  rare  instances,  in  children,  the  false 
membrane  has  extended  into  the  larynx,  causing  suffocation. 
Usually  the  disease  terminates  in  recovery  in  about  a  week  or 
ten  days. 

Chronic  or  recurrent  herpes  of  the  throat  is  encountered  in  rare 
instances. 


GANGRENOUS    PHARYNGITIS.  209 

How  is  common  membranous  sore-throat  to  be  distinguished 
from  diphtheria? 
The  diagnosis  is  sometimes  very  difficult,  and,  when  in  doubt, 
the  safer  plan  is  to  consider  the  case  one  of  diphtheria  until 
bacteriologic  investigation  has  been  made.  As  a  rule,  how- 
ever, the  islet-like  distribution  of  the  patches  of  fibrinous 
exudation  covering  the  ulcers  left  by  rupture  of  the  vesicles  of 
herpes  is  quite  ditt'erent  from  the  appearance  presented  by  the 
coherent,  continuous  mass  of  thick,  yellowish  or  grayish  mem- 
brane observed  in  diphtheria.  Herpes  is  more  frequent  upon 
the  palate  aud  tonsils.  Diphtheria  usually  involves  the  phar- 
ynx extensively.  The  constitutional  symptoms  of  diphtheria 
are,  as  a  rule,  much  more  profound  than  those  of  herpetic 
sore-throat.  Herpes  of  the  lips  often  coexists  with  herpetic 
sore-throat,  rarely  with  diphtheria.  Diphtheria  is  contagious. 
Herpes  is  non-contagious.  A  specific  bacillus  causes  the  one 
and  not  the  other. 

Gangrenous  Pharyngitis. 

What  is  gangrenous  pharyngitis  ? 

Gangrenous  pharyngitis,  or  2jutrid  sore-throat,  may  originate 
independently  of  any  other  malady  or  may  follow  ordinary 
forms  of  pharyngitis,  or  the  sore-throat  of  the  exanthemata,  or 
of  dysentery,  or  of  typhus  or  of  typhoid  fever.  It  sometimes 
occurs  in  cases  of  tuberculosis.  Constitutional  symptoms  are 
typhoid  in  type.  The  local  symptoms  are  those  of  violent  inflam- 
mation of  the  mucous  membrane  of  the  tonsils,  palatine  folds, 
and  walls  of  the  pharynx,  which  soon  become  covered  with 
gangrenous  patches.  The  destructive  process  rapidly  extends, 
sometimes  into  the  esophagus,  the  larynx,  and  the  nares. 
Sometimes  the  process  is  extremely  limited,  as  to  the  tonsils. 
Erosion  of  blood-vessels  may  cause  fatal  hemorrhage. 

How  is  gangrenous  sore-throat  to  be  distinguished  from  diph- 
theria ? 
In  gangrene,  the  patches  are  grayish-black  in  color  from  the 
outset,  while  the  pseudo-membrane  of  diphtheria  becomes  dark 
only  as  the  disease  progresses. 

14 


210  ESSENTIALS    OF    DIAGNOSIS. 

Swelling  of  the  cervical  glands  is  unusual  in  putrid  sore- 
throat,  and  the  characteristic  odor  of  gangrene  is  almost  un- 
mistakable. 

Diphtheria  presents  a  specific  bacillus,  while  the  organism 
active  in  gangrenous  sore-throat,  if  specific,  has  not  been 
identified. 

Eetro-pharyngeal  Abscess. 

What  are  the  symptoms  of  retro-pharyngeal  abscess  ? 

Suppuration  in  the  retro-pharyngeal  tissues  is  most  commonly 
a  result  of  destructive  disease  of  the  cervical  vertebrae  ;  it  may 
also  be  due  to  inflammation  of  the  lymphatic  glands  or  of  the 
connective  tissues,  resulting  from  traumatism  or  developed  in 
the  course  of  infectious  disease,  or  by  extension  from  adjacent 
disease.  The  affection  is  more  common  in  children  than  in 
adults,  and  in  tuberculous  or  syphilitic  than  in  other  subjects. 
There  may  be  an  initial  chill,  with  nausea  and  vomiting,  fol- 
lowed by  considerable  elevation  of  temperature  and  acceleration 
of  pulse.  In  some  cases,  especially  in  adults,  the  disease  is 
insidious  in  onset  and  course,  and  febrile  movement  is  absent. 

There  are  soreness  of  the  throat,  with  pain  and  difficulty  of 
swallowing;  orthopnea;  suffocative  paroxysms;  and  noisy 
breathing;  the  voice  is  muffled  or  nasal.  The  head  is  often 
thrown  back.  There  is  little  or  no  cough.  There  may  be  re- 
gurgitation of  fluids  through  the  nose. 

The  neck  may  be  swollen  and  tender  to  touch,  especially  be- 
hind the  angle  of  the  jaw,  in  front  of  the  sterno-mastoid  muscle. 
The  submaxillary  glands  may  suppurate  and  fluctuation  become 
evident.  The  diagnosis  is  to  be  made  by  inspection  and  palpa- 
tion. 

On  inspection  of  the  throat  the  posterior  wall  of  the  pharynx 
may  appear  tumid,  or  a  distinctly  circumscribed  projection  may 
be  seen,  the  mucous  membrane  over  and  around  the  swelling 
being  reddened,  perhaps  ecchymotic. 

The  abscess  may  be  so  hidden  that  the  use  of  the  mirror,  or 
digital  exploration,  may  be  necessary  for  its  detection. 

On  'paliKition  fluctuation  may  be  elicited. 


ESOPIIAGITIS  —  STRICTURE    OF    THE    ESOPHAGUS.     211 

THE  ESOPHAGUS. 

Esophagitis. 

What  are  the  clinical  features  of  esophagitis  ? 

Inficunmation  of  the  esopJiagus  may  arise  from  the  ingestion 
of  irritating  food,  corrosive  substances  or  foreign  bodies,  or  as  a 
secondary  manifestation  of  some  primary  disorder,  local  or  con- 
stitutional. The  mucous  membrane  is  thickened,  perhaps 
eroded,  sometimes  the  seat  of  false  membrane.  Ulceration  may 
take  place.  The  condition  is  attended  with  pain  in  deglutition 
and  dull  pain  behind  the  sternum. 

In  connection  with  cardiac  insufficiency  and  cirrhosis  of  the 
liver  the  esophageal  veins  may  be  enlarged  and  varicose,  and 
give  rise  to  hemorrhage,  which  may  be  fatal. 

Stricture  of  the  Esophagus. 

What  are  the  symptoms  of  stricture  of  the  esophagus  ? 

The  esophagus  may  be  narrowed  b}^  new-growths  in  its  walls; 
by  cicatrices  resulting  from  previous  ulceration  or  syphihtic  or 
tuberculous  disease  or  from  the'  ingestion  of  corro.sive  sub- 
stances ;  by  pressure  from  without,  as  by  an  aneurism  or  a  new- 
growth  ;  or  as  a  congenital  malformation.  The  constriction  is 
most  commonly  near  the  upper  or  the  lower  extremity  of  the 
tube.  Deglutition  is  interfered  with,  so  that  it  may  be  possible 
to  swallow  onlj^  liquids.  If  the  narrowing  is  decided,  a  pouch 
forms  above  the  seat  of  constriction,  in  which  considerable 
quantities  of  food  accumulate,  to  be  periodically  rejected. 
Esophageal  growths,  if  favorably  situated,  can  sometimes  be 
detected  by  the  methods  of  laryngoscopy.  Esophagoscojjy  has 
not  yet  been  sufficiently  developed  for  diagnostic  purposes.  On 
auscultation  to  the  left  of  the  spinal  column  the  sound  gener- 
ated by  swallowed  water  may  be  found  retarded.  Conclusive 
evidence  of  the  exister.o'e  of  a  stricture  of  the  esophagus  is  fur- 
nished by  the  resistance  encountered  in  the  introduction  and 
withdrawl  of  a  bulbous  bougie  ;  if  aneurism  be  suspected,  this 
means  of  exploration  is  not  permissible. 


212  ESSENTIALS   OF    DIAGNOSIS. 

How  are  functional  and  organic  strictures  of  the  esophagus  to 
be  differentiated  ? 

Spasmodic  contraction  of  the  esophagus  is  apt  to  result  from 
the  presence  of  a  foreign  body,  as  a  bougie,  in  the  gullet.  Spasm 
of  the  esophagus  [esophagismus) ^  in  a  degree  sufficient  to  give 
rise  to  symptoms,  sometimes  occurs  in  hysterical  persons.  Under 
the  conditions  last  named,  food  may  be  obstinately  rejected  and 
a  considerable  degree  of  emaciation  result.  The  introduction 
of  a  bougie  may  be  met  with  some  resistance,  which,  however, 
slowly  yields  to  gentle  pressure.  Careful  observation  will  dis- 
close the  fact  that  not  all  the  food  taken  is  rejected.  A  powerful 
impression,  judiciously  made,  may  at  once  cause  the  disappear- 
ance of  the  symptoms, which  occur,  without  discoverable  cause, 
in  a  person  with  other  hysterical  attributes. 

THE  STOMACH. 

How  is  the  acidity  of  the  gastric  contents  determined? 

If  the  gastric  contents  are  acid  from  any  cause  they  will  red- 
den blue  litmus-paper.  In  the  presence  of  free  acid  they  will 
cause  in  Congo-red  a  change  to  blue,  which  disappears  when 
heat  is  applied  if  the  acid  be  organic  and  persists  if  it  be 
hydrochloric. 

What  are  the  most  available  tests  for  hydrochloric  acid  ? 

Topf^r's  test  consists  in  the  use  of  a  0.5%  solution  of  dimethyl- 
amido-azobenzol,  a  cherry-red  color  developing  in  the  presence 
of  free  hydrochloric  acid. 

Gunzburg's  test  consists  in  .the  use  of  a  solution  of  vanillin  1 
part,  phloroglucin  2  parts,  absolute  alcohol  30  parts,  a  carmine- 
red  color  resulting  on  application  of  gentle  heat  when  free 
hydrochloric  acid  is  present. 

Boas'  test  consists  in  the  use  of  a  solution  of  5  parts  of  resub- 
limed  resorcin,  3  parts  of  cane-sugar,  100  parts  of  94%  alcohol, 
a  rose-red  or  vermilion-red  color  developing  in  the  presence 
of  free  hydrochloric  acid  when  gentle  heat  is  applied. 

How  is  the  total  acidity  of  the  gastric  contents  determined  ? 

A  known  quantity  of  the  gastric  contents  is  titrated  with  a 
decinormal  solution  of  sodium  hydroxid,  phenolphthalein  being 


THE   STOMACH.  213 

used  as  an  indicator,  the  number  of  cu.cm.  of  the  solution  em- 
ployed being  converted  into  terms  of  hydrochloric  acid. 

How  is  the  presence  of  lactic  acid  in  the  gastric  contents 
determined  ? 

Uffelinann's  test  consists  in  the  use  of  a  solution  of  5  drops  of 
a  strong  solution  of  carbolic  acid,  5  drams  of  water,  and  2  drops 
of  a  solution  of  ferric  chlorid,  which  gives  rise  to  a  canary- 
yellow  color  in  the  presence  of  lactic  acid. 

How  are  the  functions  of  the  stomach  studied  ? 

By  means  of  an  investigation  of  its  digestive  activity,  of  its 
motor  activity  and  of  its  absorptive  activity.  For  these  purposes 
test-meals  are  employed.  Ewald  and  Boas'  test-breakfast  con- 
sists of  from  an  ounce  to  an  ounce  and  a  half  of  wheat-bread 
and  from  ten  to  twelve  ounces  of  water  or  weak  tea  without 
milk  or  sugar.  The  gastric  contents  are  examined  after  an 
hour,  Riegel's  test-dinner  consists  of  twelve  ounces  of  soup,  six 
ounces  of  beefsteak,  an  ounce  and  a  half  of  wheat-bread  and  six 
ounces  of  water.  The  contents  of  the  stomach  are  examined 
after  four  hours. 

How  is  the  digestive  activity  of  the  stomach  determined  ? 

A  tablet  of  three  or  four  grains  of  potassium  iodid  is  en- 
closed in  a  bit  of  thin  vulcanized  rubber  tubing,  the  ends  of 
which  are  carefully  folded  over,  and  the  whole  is  tied  with 
three  or  four  strands  of  fibrin.  This  is  swallowed  after  a  test- 
breakfast  and  the  saliva  is  tested  for  iodin,  which  normally 
should  appear  within  two  hours. 

How  is  the  presence  of  pepsin  in  the  gastric  contents  demon- 
strated ? 

The  digestion  within  a  few  hours  of  coagulated  egg-albumin, 
fibrin  or  serum-albumin  by  the  gastric  contents  kept  at  body- 
temperature  indicates  the  presence  of  pepsin. 

How  is  the  presence  of  lab-ferment  or  rennet-ferment  in  the 
gastric  contents  demonstrated? 

The  coagulation  within  fifteen  minutes  of  neutralized  milk 
by  an  equal  quantity  of  neutralized  gastric  contents  kept  at 
body-temperature  indicates  the  presence  of  lab-ferment  or  ren- 
net-ferment. 


214  ESSENTIALS    OF    DIAGNOSIS. 

How  is  the  motor  activity  of  the  stomach  determined? 

By  the  time  that  elapses  after  the  ingestion  of  lifteen  grains 
of  salol  in  a  gelatin  capsule  at  the  height  of  digestion  before  the 
urine  yields  a  violet  color  on  the  addition  of  a  drop  or  two  of  a 
neutral  solution  of  ferric  chlorid.  Normally  this  takes  place 
within  from  half  an  hour  to  an  hour  and  a  quarter. 

How  is  the  absorptive  activity  of  the  gastric  mucous  mem- 
brane determined  ? 

By  the  time  that  elapses  after  ingestion  of  two  or  three  grains 
of  potassium  iodid  carefully  enclosed  in  a  gelatin  capsule  before 
iodin  appears  in  the  saliva,  as  shown  by  starch-paper  being 
made  blue.  Normally  this  should  take  place  within  ten  or 
fifteen  minutes. 

Neuroses  of  the  Stomach. 

What  are  the  neuroses  of  the  stomach? 

The  functional  activity  of  the  stomach  may  be  deranged  in 
the  absence  of  appreciable  structural  alteration.  The  disorder 
may  be  motor ^  sensory  or  secretory. 

Thus,  there  may  be  increased  motor  activity  of  the  stomach 
{hyperkinesis,  supermobility) ,  causing  premature  discharge  of  the 
chyle  into  the  duodenum.  Peristaltic  unrest  consists  in  unduly 
active  movement  of  the  stomach  (and  sometimes  also  of  the 
intestine)  after  the  taking  of  food,  with  borborygmi  and  gur- 
gling. Nervous  eructations  may  occur  paroxysmally  and  be  in- 
duced by  emotional  disturbance.  Nervous  vomiting  may  take 
place  independently  of  the  ingestion  of  food  and  be  unattended 
with  nausea.  It  consists  rather  in  regurgitation  than  in  forcible 
ejection  of  the  contents  of  the  stomach.  Rumination  or  mery- 
cism  consists  in  regurgitation  of  food,  which  may  then  be  re- 
chewed.  There  may  further  be  spasm  or  insufficiency  of  the 
cardia,  spasm  or  insufficiency  of  the  pylorus  and  general  atony  of 
the  stomach. 

Among  the  sensory  neuroses  may  be  mentioned  hyperesthesia, 
gastralgia  or  gastrodynia,  bulimia  (excessive  hunger),  akoria  (ab- 
sence of  a  sense  of  satiety)  and  nervous  anorexia. 

The  secretory  neuroses  include  excessive  acidity  of  the  gastric 


SPLANCHNOPTOSIS  —  ACUTE    GASTRITIS.  215 

juice  {hyperacidity,  hyperchlorhydria) ;  excessive  secretion  of  the 
gastric  juice  (super secretion),  which  may  be  intermittent  or  contin- 
uous;  and  deficient  acidity  of  the  gastric  juice  {subacidity,  anacid- 
ity).  With  the  last  there  may  be  associated  also  deficiency  of  the 
digestive  fet^nents  {achy Ha  gastnca). 

Splanchnoptosis. 

What  is  splanchnoptosis  ? 

One  or  more  of  the  abdominal  viscera  may  be  unduly  free 
or  mobile  or  variously  displaced  in  consequence  of  excessive 
length  or  relaxation  of  the  supporting  ligaments.  In  addition 
to  the  physical  signs  of  visceral  displacement  and  manifesta- 
tions of  digestive  derangement  neurasthenic  symptoms  are 
often  present. 

Gastralgia. 

What  is  gastralgia  or  gastrodynia  ? 

Gastric  pain  is  usually  symptomatic  of  inflammation,  ulcera- 
tion or  neoplasm.  It  may,  however,  occur  independently  of 
recognizable  structural  disease,  and  is  then  considered  a  neu- 
rosis— neuralgia  of  the  stomach.  The  pain  of  neuralgia  is  spas- 
modic, of  a  cutting  character,  usually  rather  brief  in  duration, 
shooting  and  shifting  in  seat,  and  occurs  spontaneousl}^  or  im- 
mediately after  the  ingestion  of  food.  It  may  induce  and  be 
relieved  by  vomiting  or  eructation.  It  is  relieved  by  heat  or 
pressure.  It  is  not  accompanied  by  vomiting  of  blood  or  by  the 
usual  manifestations  of  disordered  digestion.  Other  neurotic 
symptoms  may  coexist. 

Acute  Gastritis. 

What  are  the  symptoms  of  acute  gastritis  ? 

Acute  gastritis  results  from  the  entrance  of  irritating  matters 
into  the  stomach.  It  varies  in  degree  in  accordance  with  the 
intensity  of  the  causative  irritant.  The  milder  attacks  are 
sometimes  called  '■'■  acicte  gastric  catarrh''''  or  '■^  acute  indigestion.'''' 


216  ESSENTIALS    OF    DIAGNOSIS. 

Acute  gastric  catarrh  may  complicate  infectious  diseases,  or  its 
exciting  cause  may  escape  detection.  Phlegmonous  or  suppur- 
ative, membranous  and  mycotic  forms  of  gastritis  have  also 
been  described. 

The  sym]}toms  are  anorexia,  nausea,  vomiting,  often  epigastric 
pain  and  tenderness  ;  in  a  severe  attack,  the  face  is  pale  and 
anxious,  the  pulse  small  and  firm ;  the  skin  may  be  cold  and 
clammy  ;  there  may  be  moderate  elevation  of  temperature;  syn- 
cope and  collapse  may  occur.  The  vomited  matters  consist  of 
the  contents  of  the  stomach,  mucus,  perhaps  bile,  and  sometimes 
blood.  There  is  often  violent  retching,  without  expulsion  of  the 
contents  of  the  stomach,  or  occurring  when  the  organ  is  empty. 
In  addition  there  are  commonly  headache  and  thirst.  The 
tongue  may  be  red  and  angry.  Perforation  of  the  walls  of  the 
stomach  may  take  place.  Peritonitis  may  develop.  The  intes- 
tines are  not  likely  to  entirely  escape. 

How  are  the  gastric  symptoms  occurring  at  the  onset  of  acute 
febrile  disorders  or  in  the  course  of  cerebral  disease  to 
be  distinguished  from  the  symptoms  of  acute  gastritis? 

The  vomiting  of  acute,  febrile  disorders,  or  of  cerebral  dis- 
ease, is  not  dependent  upon  the  ingestion  of  food  ;  nor  is  it 
necessarily  attended  with  nausea,  coated  tongue,  or  pain  in  the 
epigastrium.  Tenderness  is  not  common.  If  symptoms  indicative 
of  a  constitutional  affection  have  not  been  obtrusive,  careful 
investigation  will  succeed  in  detecting  them  at  once,  or  after  the 
lapse  of  a  variable  period,  ^o  single  symptom,  but  an  associa- 
tion of  symptoms  establishes  the  diagnosis. 

How  are  acute  gastritis  and  intestinal  obstruction  to  be  differ- 
entiated ? 

The  vomiting  of  intestinal  obstruction  usually,  but  not 
invariably,  becomes  fecal ;  the  rolling  of  the  obstructed  intes- 
tines may  be  apparent  through  the  abdominal  walls.  The 
matter  vomited  in  acute  gastritis  consists  largel}'  of  mucus, 
perhaps  of  some  blood,  and  shreds  of  mucous  membrane  ;  while 
there  is  a  history  of  irritation,  poisoning,  or  indiscretion  in 
diet.  Obstinate  constipation  attends  obstruction  ;  acute  gas- 
tritis is  rather  likel}^  to  be   associated  with  diarrhea.     If  an 


CHRONIC    GASTRITIS.  217 

obstruction  of  the  bowel  be  not  speedily  removed,  death  results. 
Recovery  from  the  milder  forms  of  acute  gastritis  may  take  place 
spontaneously. 

Chronic  Gastritis. 

What  are  the  symptoms  of  chronic  gastritis  ? 

Chronic  gastritis  or  chronic  gastric  catarrh  is  the  principal 
factor  in  the  production  of  dyspepsia.  The  symptoms  differ 
from  those  of  acute  gastritis  not  only  in  degree,  but  also  in 
character.  There  are  many  varieties  of  the  affection  but  the 
general  phenomena  are  the  same  in  all.  The  more  or  less  per- 
sistent ingestion  of  food  or  drink,  improper  in  quality  or  exces- 
sive in  quantity,  is  the  principal  cause  of  chronic  gastric  catarrh. 
The  disorder  manifests  itself  by  nausea,  vomiting,  impaired 
appetite,  coated  tongue,  epigastric  discomfort,  aggravated  by 
the  ingestion  of  food,  flatulence,  eructations,  pyrosis,  acidity, 
bad  taste,  offensive  breath,  and  palpitation  of  the  heart.  There 
is  dull,  diffuse  abdominal  pain,  relieved  by  vomiting.  There 
is  also  diffuse  epigastric  tenderness.  The  vomiting,  as  a  rule, 
takes  place  from  one-and-a-half  to  two  hours  after  the  ingestion 
of  food.  Constipation  is  common;  sometimes  there  is  diar- 
rhea, with  undigested  food  in  the  stools.  Usually  there  is  in- 
creased thirst.  The  complexion  is  often  sallow.  Headache  is 
frequent  and  vertigo  not  uncommon.  There  may  be  loss  of 
flesh  and  anemia.  Mental  operations  are  in  many  cases  tem- 
porarily sluggish,  depression  ("blues")  is  not  rare,  and  sleep- 
lessness or  disturbed  sleep  and  disquieting  dreams  are  quite 
common. 

If  much  accumulation  of  undigested  and  decomposing  food 
takes  place,  or  impairment  of  the  motor  activity  of  the  stomach 
becomes  decided,  diliitation  of  the  viscus  (gasirectasia)  may  re- 
sult. A  succession  of  meals  may  be  taken  before  vomiting  occurs  ; 
when  it  does,  astounding  quantities  of  liquid,  containing  the 
macerated  and  fermenting  remains  of  food,  and  various  fungi 
(especially  the  yeast-fungi  and  sarcinse),  are  ejected.  The  quan- 
tity of  hydrochloric  acid  in  the  gastric  juice  may  or  may  not  be 
changed.     Organic  acids  of  fermentation  are  usually  present. 


218  ESSENTIALS   OF   DIAGNOSIS. 


Dilatation  of  the  Stomach — Gastrectasis. 

What  are  the  clinical  features  of  gastrectasis  ? 

Dilatation  of  the  stomach  may  be  acute  or  chronic.  It  may 
follow  ingestion  of  large  quantities  of  food  or  drink,  obstruction 
at  the  pylorus  or  atony  of  the  muscular  coat  from  any  cause. 
In  addition  to  dyspeptic  symptoms  there  occurs  at  intervals 
vomiting  of  large  quantities  of  offensive  fluid  containing  per- 
haps particles  of  food  taken  long  before.  The  upper  part  of 
the  abdomen  may  be  prominent  and  the  enlargement  of  the 
viscus  may  be  appreciable  on  inspection.  The  area  of  gastric 
percussion-tympany  is  increased  when  the  stomach  is  empty 
and  that  of  dulness  when  it  is  filled.  Splashing  can  sometimes 
be  felt  and  heard.  The  diagnosis  will  sometimes  be  facilitated 
by  inflation  of  the  stomach. 

Gastrectasis  is  to  be  distinguished  from  enlargement  of  the 
stomach — megagastria — and  from  displacement  of  the  stomach 
— gastroptosis. 

Gastric  Ulcer. 

What  are  the  symptoms  of  gastric  ulcer  ? 

Destruction  of  the  mucous  coat  of  the  stomach  may  be  a 
result  of  acute  gastritis.  More  commonly,  however,  gastric 
ulceration  develops  in  the  course  of  chronic  gastric  catarrh, 
especially  in  anemic  women  with  impaired  nutrition.  Long- 
continued  hyperacidity  may  be  a  contributing  cause.  In  some 
cases,  ulcers  of  the  stomach  result  from  occlusion  or  obstruction 
of  gastric  vessels.  Gastric  ulcer  is  not  infrequent  in  cases  of  cir- 
rhosis of  the  liver.  The  symptoms  are  sometimes  obscure,  and 
the  disease  may  go  unrecognized  until  suddenly  perforation  and 
death  result.  Symptoms  of  gastric  catarrh  are  usually  present, 
with  vomiting,  impaired  appetite,  discomfort  after  meals,  flatu- 
lence, acidity,  coated  tongue.  There  are  acute  pain  and  marked 
tenderness  in  the  epigastrium  or  hypochondrium,  also  some- 
times in  the  lower  dorsal  or  upper  lumbar  region.  Pain  and 
tenderness  over  or  near  the  spinal  column  opposite  the  site  of 
epigastric  pain  are  quite  characteristic  of  gastric  ulcer.     The 


GASTRIC    ULCER.  219 

pain  and  accompanying  tenderness,  anteriorly  as  well  as  pos- 
teriorly, are  most  frequently  distinctly  circumscribed.  Pain  is 
aggravated  by  the  ingestion  of  food,  especially  solid  food,  and 
relieved  by  vomiting,  -which  usually  occurs  soon  after  food  is 
taken.  The  vomited  matters  are  often  blood-streaked ;  or  a 
considerable  quantity  of  blood,  bright-red  in  hue,  or  discolored 
by  the  gastric  juice,  is  vomited.  Following  hematemesis  the 
stools  contain  more  or  less  black,  tarry  matter.  The  acidity  of 
the  gastric  juice,  and  especially  the  quantity  of  free  hydro- 
chloric acid,  is  usually  increased.  Anemia  is  a  common  attend- 
ant upon  gastric  ulcer  and  there  may  be  considerable  loss  of 
weight.  Dyspnea  and  palpitation  are  its  concomitants.  There 
are  often  great  emaciation  and  profound  prostration.  Occasion- 
ally perforation  of  the  walls  of  the  stomach  results;  if  adhesive 
inflammation  have  occurred,  adjacent  structures,  as  liver  or 
pancreas,  may  constitute  the  floor  of  the  ulcer ;  otherwise  fatal 
peritonitis  ensues.  Cicatrization  may  cause  deformity  of  the 
stomach  and  obstruction. 

Ulceration  of  the  duodenum  arises  under  much  the  same  condi- 
tions as  gastric  ulceration,  although  more  common  in  males, 
and  in  some  instances  being  related  especially  to  burns  of  the 
surface  of  the  body.  The  pain  after  eating  occurs  usually  later 
than  with  gastric  ulcer,  the  tenderness  is  fjrone  to  be  further  to 
the  right  and  lower,  and  hematemesis  is  less  likely,  and  melena 
more  likely  to  take  place. 

How  is  chronic  gastritis  to  be  distinguished  from  gastric  ulcer? 

With  ulceration  of  the  stomach  are  associated  the  symptoms 
of  chronic  gastritis,  but  in  addition  there  are  the  exquisite 
localized  epigastric  pain  and  tenderness,  which  differ  from  the 
diffuse  soreness  of  simple  gastritis.  Hematemesis  is  usual  in 
ulcer  of  the  stomach  and  less  usual  in  chronic  gastritis  of  other 
than  alcoholic  origin ;  and  the  blood  in  the  latter  case  is  not 
likely  to  be  bright  in  color  or  of  frequent  appearance  in  the 
vomit.  In  gastritis  vomiting  occurs  not  only  after  taking  food, 
but  not  uncommonly  on  an  empty  stomach  as  well.  The  vomit- 
ing of  ulceration  is  usually  brought  on  by  eating.  Chronic  gas- 
tritis responds  more  readih^  than  gastric  ulcer  to  judicious 
treatment.    The  age  and  sex  of  the  patient  sometimes  help  the 


220  ESSENTIALS    OF    DIAGNOSIS. 

diagnosis,  as  ulcer  is  most  frequent  in  young  persons  and  espe- 
cially in  anemic  girls. 

How  are  gastric  ulceration  and  gastralgia  to  be  differentiated? 

The  one  is  and  the  other  is  not  attended  with  hematemesis 
and  possibly  melena.  The  pain  of  gastralgia  is  more  likely  to 
be  relieved  and  that  of  ulcer  to  be  aggravated  by  the  taking  of 
food  and  by  pressure.  Dyspeptic  symptoms,  anemia,  impaired 
nutrition  and  increased  acidity  of  the  gastric  juice  are  all  more 
common  with  ulcer  than  with  gastralgia. 


Carcinoma  of  the  Stomach. 

What  are  the  symptoms  of  carcinoma  of  the  stomach  ? 

Carcinoma  of  the  stomach  appears  principally  in  two  forms. 
In  the  one  the  cellular  element  predominates  ;  in  the  other,  the 
fibrous.  The  former  involves  the  coats  of  the  body  of  the 
stomach ;  the  latter,  almost  exclusively  the  pylorus.  Either 
may,  however,  be  circumscribed  or  diffuse.  The  symptoms 
occasioned  differ  in  each  case.  When  the  body  of  the  stomach 
is  involved  the  symptoms  are  those  of  an  aggravated  chronic 
gastritis  :  impaired  appetite,  pain  after  meals,  sometimes  vomit- 
ing, with  slow  emaciation.  The  hydrochloric  acid  of  the  gastric 
juice  is  usually  diminished  and  sometimes  wanting ;  and  lactic 
acid  is  often  present.  Among  the  many  bacteria  found  in  the 
gastric  contents  a  long,  non-motile  bacillus  has  been  isolated 
and  is  believed  to  be  responsible  for  the  production  of  lactic 
acid.  Often  there  is  febrile  elevation  of  temperature.  As  time 
goes  on,  ulceration  takes  place  in  the  iieoplasm,  with  the  addi- 
tion of  the  S3anptoms  of  this  condition :  severe,  deep-seated 
pain  in  the  region  of  the  epigastrium,  aggravated  by  the  inges- 
tion of  food,  vomiting  of  blood-streaked  matter  and  of  dis- 
colored blood  presenting  an  appearance  of  coffee-grounds.  The 
stools  contain  tarry  matter,  from  disorganized  blood.  With 
the  infiltration  of  the  walls  of  the  stomach,  adhesions  are 
formed  with  adjacent  organs,  which  may  be  progressively  in- 
vaded.    Perforation  may  take  place. 


CARCINOMA    OF    THE    STOMACH.  221 

When  tho  new-growth  involves  the  pylorus,  a  characteristic 
feature  is  dilatation  of  the  stomach.  The  organ  may  be  con- 
siderably displaced  by  the  weight  of  the  tumor.  Emaciation 
ensues  ;  while  the  development  of  the  carcinomatous  cachexia 
is  of  diagnostic  significance.  The  feature  without  the  establish- 
ment of  which  Ihe  diagnosis  of  carcinoma  of  the  stomach  is 
doubtful  is  the  presence  of  a  tumor  in  the  epigastrium.  In 
scirrhus  of  the  pylorus  death  results  from  exhaustion,  as  a 
result  of  inanition  ;  in  cellular  carcinoma  metastasis  plays  a 
prominent  part  in  determining  a  fatal  issue. 

How  are  carcinoma  and  ulceration  of  the  stomach  to  be  differ- 
entiated ? 

The  similitude  between  the  symptoms  of  ulcer  of  the  stomach 
and  those  of  carcinoma  of  the  stomach  is  sometimes  so  great 
that  the  diagnosis  is  extremely  difficult.  The  detection  of  a 
tumor  in  the  area  occupied  by  the  stomach  is  strong  evidence, 
although  a  cicatrized  gastric  ulcer  may  present  like  signs.  In 
its  absence,  a  cachexia  or  the  detection  of  enlarged  glands  or 
new-growths  at  other  parts  of  the  body  may  afford  corrobora- 
tive evidence.  While  the  symptoms  of  ulceration  maj^  set  in  ] 
acutely,  and  rapidly  assume  a  grave  aspect,  they  may  on  the 
other  hand  be  comparatively  mild  ;  recover}'  is  the  rule.  The 
symptoms  of  carcinoma  are  more  slowly  developed,  more  per- 
sistent and  more  profound  than  those  of  ulcer,  and  the  pro- 
gress of  the  case  reveals  its  malignancy.  If  the  pylorus  is  in- 
volved, vomiting  does  not  take  place  for  some  time  after  food 
has  been  taken,  while  both  in  ulceration  and  in  cellular  carci- 
noma of  the  body  of  the  stomach  vomiting,  when  it  occurs,  takes 
place  early.  Obstruction  of  the  pylorus  by  carcinoma  occasions 
dilatation  of  the  stomach.  Before  the  fortieth  year  of  life  ulcera- 
tion is  the  more  common  ;  after  forty,  carcinoma.  In  ulcer,  the 
gastric  ulcer  hydrochloric  acid  is  often  excessive  ;  in  carcinoma, 
often  wanting.  In  simple  ulcer,  sudden,  more  or  less  profuse 
hemorrhages  occur  ;  hence  the  blood  is  often  bright,  and  when 
discolored  it  is  a  viscid  fluid  or  coagulated  in  coherent  clots.  In 
carcinomatous  ulcer  there  is  a  slight  but  more  or  less  continuous 
oozing;  hence  vomiting  of  blood  rarely  occurs  apart  from  the 


222  ESSENTIALS    OF    DIAGNOSIS. 

admixture  with  food  of  the  disorganized  "coffee-grounds"  sedi- 
ment. 

How  is  carcinoma  or  sarcoma  of  the  omentum  to  be  distin- 
guished from  carcinoma  of  the  stomach  ? 

The  detection  of  a  tumor  in  the  region  of  the  epigastrium  is 
not  exclusively  indicative  of  carcinoma  of  the  stomach.  The 
omentum  may  be  the  seat  of  carcinoma  or  sarcoma.  In  such  a 
case  the  symptoms  of  gastritis  are  not  necessarily  present ;  in 
particular  the  vomiting  of  matter  resembling  coffee-grounds  is 
wanting. 

How  is  carcinoma  of  the  stomach  to  he  distinguished  from  carci- 
noma of  the  pancreas  ? 

It  may  be  impossible  to  decide  from  anatomic  considerations, 
especially  in  view  of  the  displacement  that  often  occurs,  whether 
a  tumor  in  the  epigastrium  is  gastric  or  pancreatic.  If  the 
former,  definite  symptoms  of  gastric  derangement  are  present  ; 
the  visceral  symptoms  of  the  latter  are  ill-defined.  The  exist- 
ence of  diabetes  and  the  imperfect  digestion  of  fats  would  point 
to  involvement  of  the  pancreas.  Jaundice  sometimes  accom- 
panies carcinoma  of  the  pancreas  from  pressure  upon  the  bile- 
ducts.  In  gastric  carcinoma  without  hepatic  complication  this 
does  not  occur. 

How  is  chronic  gastritis  to  be  distinguished  from  carcinoma  of 
the  stomach  ? 
It  is  not  sufficient  to  make  a  diagnosis  of  chronic  gastritis. 
The  existence  of  carcinoma  should,  if  possible,  always  be  ex- 
cluded. If,  in  addition  to  the  symptoms  of  gastritis,  there  is 
severe  and  persistent  pain  in  the  epigastrium,  or  pain  increased 
or  developed  after  eating,  with  vomiting  shortly  after  meals  or 
after  a  variable  interval,  the  ejected  matters  resembling  coffee- 
grounds  ;  if  there  exist  cachexia,  new-growths  in  various  parts 
of  the  body,  and  a  tumor  can  be  detected  in  the  region  of  the 
epigastrium,  the  gastritis  is  but  a  concomitant  of  the  malignant 
disease,  which,  in  the  course  of  a  year  or  eighteen  months,  is 
almost  necessarily  fatal.  Carcinoma  is  uncommon  before  forty  ; 
gastritis  may  occur  at  any  time  of  life.     The  gastric  juice  is 


THE    INTESTINES.  223 

likely  to  contain  free  hydrochloric  acid  in  nearly  all  cases  of 
chronic  gastritis,  but  there  is  usually  none  in  cases  of  gastric 
carcinoma. 

THE  INTESTINES. 

Acute  Enteritis. 

What  are  the  symptoms  of  acute  enteritis? 

Acute  inflammation  of  the  small  intestine  ma}^  vary  greatly  in 
severity,  from  a  simple  catarrh  of  the  mucous  lining  to  an  in- 
tense inflammation  involving  the  submucous  and  muscular 
tunics  and  even  the  peritoneal  investment. 

Acute  intestinal  catarrh  or  mucous  enteritis  is,  in  most  cases,  de- 
pendent upon  the  presence  of  irritating  matters  in  the  bowel, 
introduced  from  without  or  generated  within.  As  a  result, 
there  occur  diarrhea,  with  colicky  pains,  and  often  considerable 
tenderness  in  the  abdomen,  and  febrile  and  other  constitutional 
manifestations  of  varying  intensity.  The  stools  may  number 
from  three  to  six  or  more  in  twenty-four  hours ;  they  are  thin 
and  liquid,  containing  undigested  food  and  considerable  mucus, 
and  may  be  streaked  with  blood.  The  stomach  is  likely  to 
share  in  the  inflammatory  process,  and  the  symptoms  of  a  more 
or  less  intense  gastritis  are  superadded. 

When  gastro-enteritis  is  due  to  the  ingestion  of  corrosive  and 
poisonous  substances  or  to  the  ingestion  or  development  of 
ptomaines,  the  symptoms  become  more  severe,  and  collapse  and 
death  may  occur. 

In  the  severe  cases  of  acute  enteritis,  involving  the  serous,  mus- 
cular and  submucous  coats,  constipation,  or  constipation  alter- 
nating with  shght,  irritative  diarrhea,  is  the  rule  ;  actual  ob- 
struction of  the  bowel,  from  inflammation,  paralysis,  or  in- 
carceration by  bands  of  lymph,  is  not  uncommon.  The  consti- 
tutional and  local  symptoms  are  correspondingly  intense.  There 
may  be  an  initial  chill.  While  the  pain  may  be  colicky  at  first, 
it  soon  becomes  coUvStaut,  subject,  however,  to  paroxysmal  ex- 
acerbations. It  is  increased  by  pressure,  tenderness  at  times  be- 
ing exquisite.     As  in  peritonitis,  the  patient  lies  upon  his  back 


224  ESSENTIALS    OP   DIAGNOSIS. 

with  flexed  thighs,  to  relax  the  abdominal  muscles.  There  is  not 
uncommonly  a  marked  and  distressing  pulsation  to  the  right  of 
the  umbilicus.  Thirst,  nausea,  vomiting  and  retching  may  be 
decided,  even  in  the  absence  of  gastric  involvement.  Thvftver 
becomes  high  and  does  not  remit,  as  it  does  in  intestinal  catarrh. 
The  jndse  is  rapid  ;  at  first  tense  and  full ;  afterward,  small  and 
wiry.  Following  a  copious  stool,  amelioration  and  recovery  may 
ensue  ;  or  symptoms  of  failing  circulation,  with  distention  of  the 
abdomen,  hiccough,  incessant  retching,  sweating,  anuria  and 
exhaustion,  may  precede  death. 

How  are  acute  catarrhal  enteritis  and  typhoid  fever  to  be 
differentiated  ? 
Some  degree  of  inflammation  of  the  small  intestine  necessa- 
rily attends  typhoid  fever.  Occurring  as  an  independent  affec- 
tion, however,  enteritis  is  wanting  in  the  epistaxis,  the  severe 
headache,  the  rose-spots,  the  characteristic  temperature-curve, 
the  peculiar  character  of  the  stools,  the  diazo-reaction,  the 
agglutinating  reaction,  the  gravity  and  the  typical  course  and 
duration  of  the  general  infectious  disease. 


Membranous  Enteritis. 

What  is  membranous  enteritis  ? 

Membranous  enteritis,  tubular  diarrhea  or  mucous  colic,  is  a 
somewhat  uncommon  disease,  characterized  by  the  discharge 
of  mucoid  casts  of  the  bowel,  or  of  flakes  of  false  membrane. 
These  are  usually  expelled,  after  paroxysms  of  colic,  Avith  pain- 
ful straining,  in  watery  stools  containing  mucus,  sometimes 
blood,  but,  as  a  rule,  little  fecal  matter.  The  paroxysms  are 
often  preceded  by  constipation,  and  associated  with  or  followed 
by  diarrhea.  Nervous  symptoms  are  common.  The  affection 
is  obstinately  recurrent.  It  occurs  chiefly,  if  not  exclusively, 
in  hysterical  or  hypochondriacal  subjects  in  early  adult  or 
middle  life,  and  principally  in  women.  Enteroptosis  has  been 
noted  as  an  associated  condition,  and  gastric  achylia  has  been 
present  in  some  cases. 


CHOLERA    MORBUS CHRONIC    ENTERITIS.       225 

Cholera  Morbus. 

What  are  the  symptoms  of  cholera  morbus  or  cholera  nostras  ? 
Cholera  morbus  or  cholera  nostras  is  an  acute  disease,  most 
prevalent  during  the  sumijier  months  and  characterized  by 
inflammation  of  the  stomach  and  intestines.  It  is  commonly  a 
result  of  the  ingestion  of  unsuitable  and  irritating  articles 
of  diet.  The  affection  is  manifested  by  colicky  pains  in  the 
abdomen,  by  nausea,  vomiting  and  diarrhea,  by  cramps  in  the 
legs,  by  increased  thirst,  by  headache,  vertigo  and  debility,  by 
coldness  of  the  extremities,  by  prostration  and  rapid  wasting. 
Despite  the  severity  of  the  symptoms,  recovery  is  almost 
invariable. 

How  are  cholera  morbus  and  cholera  Asiatica  to  be  differen- 
tiated ? 
The  symptoms  of  cholera  morbus  and  those  of  cholera  Asiatica 
diflfer  principally  in  degree.  Cholera  Asiatica,  however,  occurs 
in  epidemics  ;  isolated  cases  are  rare.  Cholera  morbus,  on  the 
other  hand,  is  not  an  epidemic  disease.  The  mortality  from 
cholera  Asiatica  is  high  ;  recovery  from  cholera  morbus  is  the 
rule.  The  detection  of  characteristic  comma  bacilli  in  the  feces 
or  in  the  vomit  confirms  a  diagnosis  of  cholera  Asiatica. 

Cholera  Infantum. 

What  are  the  symptoms  of  cholera  infantum? 

Cholera  infantum  is  practically  gastro-enteritis  in  children. 
It  is  a  disease  of  the  summer  months,  and  is  intimately  related 
with  heat,  foul  air,  uncleanliness  and  fermentation  of  food.  It 
is  manifested  by  vomiting,  profuse  watery,  often  fetid  diarrhea, 
fever,  rapid  wasting,  depressed  fontanel,  convulsions  and  coma. 
Among  the  poor  the  fatality  of  the  disease  is  great. 

Chronic  Enteritis. 

What  are  the  symptoms  of  chronic  enteritis? 
As  chronic  enteritis  or  intestinal  catarrh  most  frequently  results 

15 


226  ESSENTIALS     OF     DIAGNOSIS. 

from  persistent  errors  in  diet,  the  symptoms  depend  upon 
retarded  and  defective  intestinal  digestion.  Pain  and  oppres- 
sion occur  at  a  time  after  the  ingestion  of  food  that  varies  with 
the  seat  of  the  morbid  process.  In  duodenal  catarrh  the  symp- 
toms appear  earlier  than  when  the  jejunum  or  ileum  is  involved. 
When  the  lower  portion  of  the  intestine  is  affected,  colicky  pains 
are  frequent.  There  may  be  persistent  diarrhea,  or  obstinate  con- 
stipation, or  diarrhea  alternating  with  constipation.  The  stools 
are  slimy  and  may  contain  undigested  food.  The  abdomen  is 
distended  ;  flatulence  and  belching  are  usual.  The  comxjlexion 
is  sallow.  The  nutrition  is  impaired.  Headache  is  common. 
Sleejp  is  disturbed  by  dreams,  while  there  is  unusual  drowsiness. 

Acute  Dysentery. 

What  are  the  symptoms  of  acute  dysentery  ? 

Acute  dysentery  is  practically  an  inflammation  of  the  large  in- 
testine, probably  dependent  upon  a  specific  infection  ;  rarely 
the  lower  portion  of  the  small  intestine  is  involved.  The  in- 
flammation may  be  of  varying  intensity.  It  may  be  catarrhal, 
ulcerative  or  diphtheritic.  There  are  slight  fever,  abdominal 
pains  of  a  griping  character  (tormina),  terminating  with  fre- 
quent, small,  slimy  stools,  streaked  with  blood,  each  evacuation 
being  attended  with  bearing-down,  burning  pain  and  muscular 
spasm  (tenesmus).  The  stools  sometimes  contain  pus,  sometimes 
shreds  of  membrane  ;  in  many  cases  the  ameba  coli  is  found. 
In  addition  there  are  headache,  vertigo,  weakness,  thirst  and 
perhaps  nausea  and  vomiting.  Dysentery  is  a  prolific  source 
of  hepatic  abscess.  Death  may  result  from  exhaustion,  or  from 
perforation  of  the  bowel. 

How  are  intussusception  of  the  bowel  and  acute  dysentery  to 
be  differentiated  ? 

In  cases  of  intussusception  of  the  bowel  the  stools  may  be 
small,  frequent,  mucous,  blood-streaked,  and  attended  with 
tenesmus.  Inquiry,  however,  will  elicit  a  history  of  abrupt 
onset  ;  examination  will  disclose  the  presence  of  a  sausage- 
ghaped  abdominal  tiimor,  perhaps  also  protrusion  of  the  bowel 


CHRONIC    DYSENTERY.  *  227 

at  the  anus.     Intussusception  is  the  more  common  in  children  ; 
dysentery,  the  more  common  in  adults. 

How  are  acute  enteritis  and  acute  dysentery  to  be  differen- 
tiated? 
The  pain  of  acute  intestinal  catarrh  is  colicky,  but  the  pecu- 
liar tormina  and  tenesmus  of  dysentery  are  wanting.  The 
stools  of  dysenter}-  are  more  frequent  than  those  of  enteritis, 
are  smaller  in  quantity,  contain  more  blood,  and  are  in  less 
degree  fecal.  Dysentery  is  more  likely  than  is  enteritis  to  be 
epidemic. 

How  are  acute  dysentery  and  typhoid  fever  to  be  differen- 
tiated? 
While  both  acute  dysentery  and  typhoid  fever  are  attended 
with  diarrhea,  the  stools  of  dysentery  are  frequent  and  small, 
perhaps  ineffectual,  and  are  composed  principally  of  blood- 
streaked  mucus  ;  the  stools  of  typhoid  fever  are  not  necessarily 
frequent,  are  larger,  often  thin  and  like  pea-soup.  The  epis- 
taxis,  the  rose-spots,  the  diazo-reaction,  the  agglutinating  re- 
action and  the  characteristic  temperature-curve  of  typhoid  fever 
are  wanting  in  acute  dysentery.  The  duration  of  dysentery  is 
briefer  than  that  of  typhoid  fever. 


Chronic  Dysentery. 

What  are  the  symptoms  of  chronic  dysentery  ? 

Dysentery  may  from  the  outset  manifest  a  tendency  to  chron- 
icity  ;  or  an  acute  dysentery  may  become  chronic.  The  symp- 
toms of  chronic  dysentery  differ  in  several  respects  from  those 
of  the  acute  disease.  Tormina  and  tenesmus  are  uncommon, 
except  with  exacerbations.  The  bowels  are  loose,  the  stools 
containing  mucus,  but  little  blood  and  membrane.  Sometimes 
diarrhea  and  constipation  alternate.  Febrile  symptoms  are 
generally  wanting ;  intermissions  occur ;  wasting  takes  place ; 
anemia  develops ;  the  complexion  becomes  sallow ;  hepatic 
abscess  may  form. 


228  ESSENTIALS    OF    DIAGNOSIS. 

Typhlitis — Appendicitis— Perityphlitis. 

"What  are  the  symptoms  of  typhlitis  ? 

Inflammation  occurs  in  the  cecum  or  the  vermiform  appen- 
dix as  a  result  of  accumulation  and  impaction  of  fecal  matters ; 
or  from  irritation  by  a  calculus,  the  nucleus  of  which  may  be 
inspissated  mucus  from  catarrh  of  the  appendix,  or  by  a  foreign 
body,  such  as  a  cherry-stone  or  a  grape-seed.  Traumatism  and 
straining  are  occasional  exciting  causes.  It  is  probable  that 
bacteria  play  an  important  exciting  part.  The  process  may 
be  catarrhal,  obliterative,  ulcerative  or  gangrenous.  The  pre- 
monitory symptoms  are  vague  and  are  frequently  mistaken  for 
simple  colic.  Diarrhea  may  alternate  with  constipation,  still 
further  misleading  the  inattentive  observer.  If  the  cecum  be 
involved,  it  becomes  paralyzed  and  distended  with  accumulated 
feces  ;  thus,  the  condition  declares  itself  primarily  by  the  symp- 
toms of  intestinal  obstruction,  by  pain,  often  severe,  and  in- 
creased by  motion,  in  the  right  iliac  fossa  and  rigbt  hip,  with 
tenderness,  a  sense  of  doughy  induration,  and  dulness  on  per- 
cussion. The  tumor  is  superficial  and  sausage-shaped,  its  long 
axis  pointing  inwards  and  downwards.  It  is  slightly  movable  ; 
gurgling  may  sometimes  be  developed.  The  pain  may  be  parox- 
ysmal or  paroxysmally  aggravated,  and  is  frequently  of  an 
agonizing  character.  There  is  usually  some  fever,  and  at  times 
the  temperature  may  reach  from  102°  to  104°  F.  Peritonitis  may 
develop,  even  without  ulceration  and  perforation  of  the  bowel, 
and  its  symptoms  then  predominate.  It  may  remain  localized 
or  become  diffused.  With  relief  to  the  obstruction,  recovery 
may  ensue,  or  collapse  may  suddenly  occur,  recovery  or  death 
following. 

If  appendicitis  alone  exist  there  may  be  no  interference  with 
the  passage  of  the  intestinal  contents,  though  constipation 
often  exists ;  and  the  evidences  of  a  tumor  in  the  iliac  fossa  are 
wanting,  unless  the  appendix  have  undergone  great  distention. 
There  are,  besides,  colicky  pain  in  the  right  iliac  fossa,  with 
localized  tenderness  most  commonly  at  a  point  where  a'  line 
from  the  anterior  superior  iliac  spine  on  the  right  to  the  um- 
bilicus crosses  the  outer  border  of  the  rectus  muscle ;  usually 


TYPHLITIS  —  APPENDICITIS  —  PERITYPHLITIS.    229 

elevation  of  temperature ;  and  nausea  and  vomiting.  The  right 
rectus  muscle  is  usually  rigid,  "on  guard,"  especially  in  the 
iliac  region,  and  sometimes  the  enlarged  appendix  can  be  felt 
through  the  abdominal  wall.  Sometimes  epigastric  pain  and 
tenderness,  with  or  without  vomiting,  are  the  initial  and  most 
prominent  symptoms.  In  ulcerative  appendicitis,  perforation 
not  rarely  results,  giving  rise  to  a  general  or  localized  purulent 
peritonitis.  This  event  may  be  announced  by  sudden  pain, 
shock,  chill  and  rise  of  temperature,  followed  by  the  develop- 
ment of  a  fluctuating  tumor  indicative  of  abscess ;  or  the  condi- 
tion may  develop  insidiously  and  be  difficult  of  recognition. 
Sometimes,  after  initial  shock  and  pain,  deceptive  improve- 
ment is  manifested.  Sudden  cessation  of  pain,  and  of  fever 
may  denote  the  occurrence  of  gangrene.  In  cases  suggestive 
of  appendicitis  surgical  exploration  may  be  a  diagnostic  neces- 
sity.    Attacks  of  appendicitis  are  prone  to  be  repeated. 

Perityphlitis,  or  inflammation  of  the  tissues  surrounding  the 
cecum  and  its  appendix,  usually  occurs  in  the  course  of  typhlitis 
or  of  appendicitis.  The  fibrous  structures  and  the  peritoneum 
are  involved  alone  or  in  association.  If  perforation  takes  place, 
an  abscess  may  form,  or  general  peritonitis  result,  or  both  com- 
plications may  be  present.  As  a  rule,  the  pus  is  shut  off  from  the 
general  peritoneal  cavity  by  a  capsule.  The  symptoms  vary  with 
the  pathologic  association.  To  those  of  the  primary  condition  are 
added  an  acute  exacerbation  of  pain  and  tenderness,  as  well  as  of 
the  general  symptoms,  perhaps  preceded  by  a  chill.  The  pain  is 
deep-seated  and  is  increased  by  flexing  the  right  thigh  upon  the 
abdomen.  Sometimes  the  patient  is  unable  to  lift  the  right  leg. 
He  usually  lies  upon  the  right  side,  with  the  thigh  semiflexed. 
If  an  abscess  forms,  there  may  be  repeated  rigors  and  a  fluctu- 
ating tumor  in  the  right  iliac  fossa.  The  tumor  is  not  super- 
ficial and  sausage-shaped  like  that  of  cecitis,  but  is  deep-seated 
and  irregular.  A  pericecal  abscess  may  sometimes  be  detected 
by  rectal  exploration.  If  peritonitis  develop,  death  may  ensue, 
from  septicemia  or  gradual  exhaustion,  or  suddenly,  with  mani- 
festations of  collapse. 


230  ESSENTIALS    OF    DIAGNOSIS. 

With  what  conditions  may  appendicitis  or  perityphlitis  be  con- 
founded ? 

Inflammations  of  the  cecum  and  its  appendix  or  inflamma- 
tion and  abscess  of  tlie  surrounding  tissue  have  been  mistaken 
for  typlioid  fever,  and  for  ^'idiopatliic  peritonitis." 

The  mistake  is  more  likely  to  be  made  when  the  inflammation 
of  the  appendix  has  been  slow  and  the  symptoms  indistinct, 
until  perliaps  perforation  occurs,  causing  a  limited  abscess  or  a 
general  septic  peritonitis.  Deep-seated  but  limited  abscess  may 
for  a  time  be  concealed  from  other  than  surgical  exploration, 
and  through  septic  poisoning  give  rise  to  the  "typhoid  state." 

Before  localizing  symptoms,  such  as  induration,  or  the  pres- 
ence of  a  fluctuating  tumor  in  the  iliac  fossa,  render  the  case 
clear,  the  occurrence  of  one  or  more  rigors,  the  absence  of  dis- 
tinctive characteristic  symptoms  of  typhoid  fever,  the  course  of 
the  temperature,  and  sometimes  the  location  of  the  tenderness, 
should  prevent  mistake.  The  location  of  the  pain  and  tender- 
ness, hovFBver,  may  be  misleading,  as  the  appendix  varies  greatly 
in  its  position  ;  and  appendicitis  has  even  been  known  to  simu- 
late hepatic  disease.  Sometimes  only  an  exploratory  incision 
can  settle  the  diagnosis. 

The  exploring  needle  or  aspirator  should  never  be  used. 

How  are  perityphlitis  and  typhlitis  to  be  distinguished  from  a 
lumbar  abscess? 

Destructive  disease  of  a  lumbar  vertebra  is  usually  followed 
by  suppuration,  the  pus  followdng  in  the  course  of  the  psoas 
muscle  and  seeking  exit  below  Poupart's  ligament.  A  collec- 
tion of  pus  forming  in  this  way  differs  from  typhlitis  or  peri- 
typhlitis by  the  absence  of  symptoms  of  intestinal  derangement. 
The  situation  of  the  tumor  is  different  in  each  case.  In  the  one 
case,  examination  will  reveal  a  deformity  of  the  spinal  column, 
with  pain  and  tenderness  in  the  lumbar  region.  The  symptoms 
are  slow  and  progressive.  They  may  be  associated  with  visceral 
tuberculosis. 

How  are  typhlitis  and  perityphlitis  in  a  woman  to  be  distin- 
guished from  an  abscess  of  the  right  ovary  ? 

An  abscess  of  the  right  ovary  is  situated  nearer  the  middle  line 
than  is  the  swelling  of  typhlitis  or  perityphlitis.   With  typhlitis 


INTESTINAL    OBSTRUCTION.  231 

or  perityphlitis  is  associated  gastro-intestirial  derangement; 
with  abscess  of  the  ovary,  uterine  and  menstrual  derangement. 
Vaginal  and  rectal  examination  may  clear  up  any  doubt. 

How  are  typhlitis  and  perityphlitis  to  be  distinguished  from 
carcinoma  of  the  cecum  ? 

The  symptoms  of  typhlitis  and  perityphlitis  are  likely  to 
appear  suddenly  ;  those  of  carcinoma  insidiously  and  progress- 
ively. Typhlitis  and  perityphlitis  are  affections  of  compara- 
tively brief  duration  ;  carcinoma  of  the  cecum  will  probably 
continue  for  a  number  of  months  after  its  detection.  The  inflam- 
matory processes  are  usually  attended  with  fever ;  carcinoma 
is  not.  When  typhlitis  or  perityphlitis  has  existed  for  some 
time,  fluctuation— indicative  of  the  occurrence  of  suppuration 
—can  be  detected  in  the  tumor  ;  the  carcinomatous  new-growth 
retains  its  original  density.  PerityphUtis  or  typhlitis  may  be 
attended  with  emaciation  and  sallowness  of  skin,  but  not  with 
the  cachexia  of  carcinoma.  When  the  cecum  is  the  seat  of 
carcinoma,  like  new-growths  are  usually  found  in  other  parts  of 
the  body. 

Intestinal  Obstruction. 

What  are  the  symptoms  of  intestinal  obstruction? 

The  lumen  of  the  bowel  may  be  obliterated  by  an  accumula- 
tion of  feces,  by  a  large  gall-stone,  by  an  intestinal  calculus 
(enterolith)  or  other  foreign  body,  by  organic  narrowing  of  the 
bowel,  by  stricture  or  neoplasm,  by  a  twist  or  volvulus,  by 
external  or  internal  constriction  and  by  incarcerated  or  stran- 
gulated hernia,  internal  or  external. 

The  condition  may  arise  in  a  subject  of  habitual  constipation 
or  of  hernia.  It  may  follow  a  violent  physical  efibrt.  It  may  be 
due  to  acute  enteritis.  From  the  onset,  or  after  a  variable 
period  during  which  no  stool  has  been  passed,  abdominal  pain 
and  rumbling  set  in.  Vomiting  ensues  ;  at  first  of  the  contents 
of  the  stomach,  then  of  yellowish -green  fluid  and  mucus ; 
finally  the  vomiting  becomes  stercoraceous.  The  apparent  con- 
stipation does  not  submit  to  ordinary  measures.  The  abdomen 
becomes  distended.     The  expression  of  the  face  is  drawn  and 


232  ESSENTIALS    OF    DIAGNOSIS. 

anxious,  the  pulse  small,  rapid  and  feeble,  the  surface  cold  and 
clammy,  and  if  the  condition  be  not  relieved  by  medicine  or 
operative  intervention,  death  is  the  inevitable  result. 

When  the  obstruction  is  not  complete,  as  in  some  cases  of 
fecal  impaction,  there  may  be  more  or  less  frequent  passages  of 
liquid  matters  somewhat  fecal,  which  the  patient  will  de- 
scribe as  diarrhea.  Inspection  of  the  stools,  and  the  evidences 
given  by  palpation  and  percussion,  of  the  presence  of  a  hard 
mass  in  the  course  of  the  bowel,  usually  in  the  transverse  or 
descending  colon,  will  prevent  error.  The  nature  of  the  obstruc- 
tion in  any  case  is  to  be  determined  principally  by  physical  ex- 
amination. In  cases  of  strangulated  hernia  the  knowledge  of 
the  existence  of  hernia  may  assist  the  diagnosis.  In  the  absence 
of  such  history,  examination  must  none  the  less  be  made,  if  only 
to  exclude  that  condition  from  among  the  possibilities  in  the  case. 
Incarceration  may  result  from  unusual  exertion  or  indiscretion 
in  diet.   Often  the  pain  is  colicky  and  referred  to  the  umbilicus. 

Intussusception. 

What  are  the  symptoms  of  invagination  or  intussusception  of 
the  bowel  ? 

Under  certain  circumstances,  not  definitely  recognized,  one 
portion  of  the  bowel  becomes  invaginated  in  another  portion. 
The  small  intestine  or  the  large  intestine,  respectively,  may  be 
alone  involved  ;  but  most  commonly  the  small  intestine  enters 
the  large  at  the  ileo-cecal  orifice.  The  occurrence  of  the  acci- 
dent is  announced  by  a  sudden  attack  of  pain,  repeated  in 
paroxysms,  followed  by  the  presence  of  a  sausage-shaped 
tumor  in  the  abdomen,  and  stools  of  a  dysenteric  character. 
Sometimes  no  fecal  matter  is  passed,  and  there  are  frequent 
discharges  of  blood-stained  mucus.  The  pain  is  intense,  and  the 
child  (for  the  aflection  is  most  common  in  children)  often  draws 
up  its  legs  close  to  the  belly.  Pressure  and  manipulation  relieve 
the  pain,  and  quiet  the  excruciating  cries  of  agony.  In  the 
course  of  a  variable  period  of  time,  blood  is  passed  by  the  bowel, 
the  pain  becomes  continuous  and  vomiting  occurs,  with  the 
symptoms  of  intestinal  obstruction.      The  invaginated  bowel 


CARCINOMA   OF   THE   INTESTINE.  233 

may  be  accessible  to  rectal  examination  ;  it  may  even  protrude 
from  the  anus  ;  it  may  slough  and  be  detached,  and  recovery 
ensue  ;  or  it  may  occasion  stenosis  of  the  bowel.  Intussuscep- 
tion is  more  common  in  children  than  in  adults,  and  in  boys 
than  in  girls. 

How  are  intussusception  and  obstruction  of  the  bowel  to  be 
differentiated  ? 
Intussusception  is  the  more  common  in  children  ;  obstruc- 
tion, in  adults.  The  symptoms  of  intussusception  appear 
abruptly ;  those  of  obstruction  are  often  abrupt  in  onset, 
though  sometimes  of  long  standing.  A  sausage-shaped  tumor 
is  characteristic  of  intussusception  ;  certain  varieties  of  ob- 
struction are  attended  with  abdominal  tumors  of  irregular 
shape.  Constipation  is  not  so  absolute  in  intussusception  as  in 
obstruction  ;  and  stercoraceous  vomiting  is  less  common  in 
the  former  than  in  the  latter.  A  discharge  of  blood  and  the 
protrusion  of  a  portion  of  bowel  from  the  anus  are  diagnostic 
of  intussusception.  Digital  exploration  of  the  rectum  will  often 
assist  in  discrimination. 

How  are  typhlitis  and  intussusception  of  the  bowel  to  be  differ- 
entiated ? 

Both  t3'phlitis  and  intussusception  may  present  a  sausage- 
shaped  tumor  in  the  right  iliac  fossa  and  be  attended  with 
severe  pain  and  the  evidences  of  intestinal  obstruction  ;  but 
intussusception,  unlike  typhlitis,  is  sudden  in  onset,  is  uncommon 
in  adults,  is  usually  afebrile,  is  likely  to  be  attended  with 
ineffectual  or  bloody  stools,  and  perhaps  to  be  accompanied 
by  protrusion  of  the  bowel  at  the  anus.  The  tumor  of  intus- 
susception is  not  necessarih'  confined  to  the  right  iliac  fossa. 

Carcinoma  of  the  Intestine. 

What  are  the  clinical  manifestations  of  carcinoma  of  the 
intestine  ? 
Carcinoma  of  the  intestine  is  most  commonly  situated  in  the 
rectum,  the  sigmoid  flexure,  the  cecum,  the  vermiform  appendix 
or  the  duodenum.  When  in  the  duodenum,  the  papilla  of  the 
pancreatic  duct  and  common  bile-duct  is  usually  involved  and 


234  ESSENTIALS   OF   DIAGNOSIS. 

jaundice  is  apt  to  result.  When  other  parts  of  the  bowel  are 
involved,  in  addition  to  the  pain  and  constitutional  phenomena 
occasioned  by  the  malignant  growth,  symptoms  of  partial  intes- 
tinal obstruction  develop.  There  is  obstinate  constipation,  and 
when  the  bowels  are  moved,  the  stools  appear  as  thin,  flat 
bands,  often  streaked  with  pus  and  blood.  On  physical  exam- 
ination a  tumor  may  be  detected. 

Intestinal  Parasites. 

What  are  the  most  common  varieties  of  intestinal  parasites  ? 

The  most  common  intestinal  parasites  belong  to  the  order  of 
vermes,  of  which  there  are  two  important  classes — cestodes^  or 
tape-worms,  and  nematodes^  or  round-worms.  The  distomata 
are  trematodes,  or  sucking-worms. 

Of  the  former  the  more  important  are  the  tsenia  solium,  the 
teenia  mediocanellata,  and  the  bothriocephalus  latus. 

Of  round-worms  the  most  common  are  the  ascaris  lumbricoides, 
the  oxyuris  vermicularis,  the  trichina  spiralis,  the  filaria  sanguinis 
hominis,  the  dracunculus  medinensis,  and  the  ankylostoma  duo- 
denale. 

The  oxyuris  vermicularis  inhabits  the  large  intestine,  the  tape- 
worms, the  lumbricoides  and  the  ankylostoma  the  small  in- 
testine; the  trichina  migrates  from  the  stomach  and  small 
intestine  into  the  muscles,  setting  up  an  irritative  fever  with 
special  symptoms,  the  condition  being  known  as  trichiniasis. 

What  symptoms  are  occasioned  by  the  presence  of  animal 
parasites  in  the  intestinal  canal? 
The  presence  of  worms  in  the  intestinal  canal  of  an  otherwise 
healthy  individual  may  occasion  no  appreciable  disturbance.  In 
other  cases,  however,  there  are  evidences  of  gastro-intestinal 
derangement,  capricious  appetite,  abdominal  uneasiness,  colicky 
pains,  possibly  diarrhea,  nausea,  vomiting,  loss  of  flesh,  debility, 
cachexia,  irregular  fever,  disturbed  sleep,  gritting  of  the  teeth, 
itching  of  the  nose  and  anus,  nervous  manifestations,  even  epi- 
leptiform convulsions.  The  filaria  gains  entrance  to  the  lymph 
or  the  blood,  where  it  causes  obstruction  and  sets  its  embrj^os 
free.    The  dracunculus  wanders  from  the  intestine  to  the  sub- 


TAENIA   SOLIUM 


235 


cutaneous  and  intermuscular  connective  tissue.     The  sucking- 
worms  cause  profound  anemia  by  abstraction  of  blood. 

The  diagnosis  of  intestinal  worms  depends  upon  the  discovery 
of  the  parasites  or  of  their  ova  in  the  stools. 


Taenia  Solium. 

What  are  the  characteristics  of  the  taenia  solium  ? 

The  tasnia  solium  (Fig.  24)  is  a  tape-worm  having  a  small  head, 
or  scolex,  and  a  slender  neck.  The  head  is  of  the  size  of  a  pin- 
head,  and  is  surmounted  by  a  circle  of  twenty-six  booklets, 
around  which  are  four  suckers.  From  the  neck  pass  off  segments, 
or  proglottides,  that  progressively  increase  in  size.  The  entire 
worm,  or  strobila,  may  be  from  seven  to  ten  feet  long  and  com- 
posed of  from  four  hundred  to  six  hundred  segments.    The  taenia 


Fig.  24. 


:#^ 


Head. 


Mature  segment. 
Tsenia  Solium,  maguified  (Heller). 


Ovum. 


solium  usually  develops  in  man  from  the  ingestion  of  "  measly" 
pork  or  the  flesh  obtained  from  swine  infected  with  cysticerci 
cellulosae,  which  in  turn  develops  in  animals  that  have  swal- 
lowed the  ova  of  the  taenia  solium.  When  ova  of  the  taenia 
solium  gain  entrance  into  the  stomach  of  man  their  capsules 
are  dissolved  and  the  embryo  parasites  invade  the  muscles,  the 
brain,  the  eye  and  other  parts,  where  they  become  encapsulated 
or  encysted,  constituting  cysticerci  cellulosse. 


236 


ESSENTIALS    OF    DIAGNOSIS. 


Taenia  Mediocanellata. 


What  are  the  characteristics  of  the  taenia  mediocanellata  ? 

The  tsenia  mediocanellata,  or  unarmed  tape-worm  (Fig.  25)  differs 
from  the  tsenia  solium  in  that  the  head  though  surmounted  by 
four  suckers,  is  without  hooklets.  The  taenia  mediocanellata 
may  attain  a  length  of  from  ten  to  twenty  feet,  and  be  composed 
of  from  eight  hundred  to  more  than  one  thousand  segments, 
which  are  longer  and  broader  than  those  of  the  tsenia  solium. 

The  tsenia  mediocanellata  is  transmitted  to  man  by  the  raw 
flesh  of  sheep  or  cows,  in  which  hosts  the  larvae  develop  from 
the  ova  of  the  tsenia  mediocanellata. 

Tape-worms  are  usually  present  in  small  numbers ;  there  is 
often  but  a  single  worm;  sometimes  there  are  two  or  three. 
About  three  months  are  requisite  for  the  development  of  a 
tape-worm. 

Fig.  25. 


Mature  segment. 
Tsenia  mediocanellata,  magnified  (Heller). 


Ovum. 


Bothriocephalus  Latus. 

What  are  the  characteristics  of  the  bothriocephalus  latus  ? 

The  bothriocephalus  laiiis  (Fig.  26)  sometimes  called  the  txnia 


ASCARIS    LUMBRICOIDES. 


237 


lata,  is  a  cestode  worm,  with  a  club-shaped  head  and  a  filament- 

FiG.  26. 


Mature  segment.  Ovum. 

Bothriocephalus  latus,  magnified  (Heller). 


Ovum :  embryo 
developed. 


ous  neck.  On  either  side  of  the  head  is  a  longitudinal  sucker. 
The  mature  segments  present  a  characteristic  stellate  appear- 
ance, dependent  upon  the  distention  of  the  uterus  with  ova. 
The  worm  may  be  from  fifteen  to  twenty-five  feet  in  length, 
and  constituted  of  from  three  thousand  to  four  thousand  seg- 
ments. It  is  thought  to  be  derived  from  fish  or  fresh-water 
molluscs. 

Ascaris  Lumbricoides. 

What  the  characteristics  of  the  ascaris  lumbricoides? 

Lumhricoid  or  round  worms  inhabit  the  small  intestine. 
Small  worms,  embryos,  or  ova,  are  supposed  to  gain  access 
to  the  alimentary  canal  of  man  through  drinking  water,  and  in 
some  instances  to  be  conve3^ed  by  the  fingers  to  the  mouths  of 
those  engaged  in  cleansing  privies  or  otherwise  handling  excre- 
ment, but  the  exact  history  of  their  development  is  unknown. 

Mature  worms  are  from  eight  to  fifteen  inches  in  length,  are 
attenuated  at  both  extremities,  and  resemble  common  earth- 
worms. Lumbricoid  worms  may  be  present  in  varying  numbers, 
from  one  to  a  dozen  or  more.  They  are  usually  multiple,  and 
in  rare  instances  may  be  so  multitudinous  as  to  occlude  the  in- 
testine.    The  worms  may  find  their  way  into  the  stomach,  and 


238 


ESSENTIALS   OF    DIAGNOSIS. 


be  expelled  by  vomiting.  They  may  pass  from  the  esophagus 
into  the  larynx  and  trachea.  They  have  in  this  way  caused 
sutibcation  in  children.     They  may  cause  occlusion  of  the  bile- 

FiG.  27. 


a,  natural  size ;   h,  head,  magnified  ;  c,  ovum,  magnified. 
Ascaris  lumbrieoides  (v.  Jaksch). 

duct  or  pancreatic  duct,  and,  though  rarely,  suppuration  of  the 
liver  or  of  the  pancreas.  They  may  also  leave  the  intestine  by 
way  of  a  perforation,  causing  peritonitis  or  fecal  abscess. 


Ankylostomiasis. 

What  is  ankylostomiasis  ? 

Ankylostomiasis  is  a  condition  arising  from  the  presence  in  the 
intestial  tract  of  the  ankylostoma  duodenale,  a  nematode  worm 
from  i  to  f  inch  long,  with  a  mouth  provided  with  tooth-like 


OCCLUSION   OF   THE   MESENTERIC   VESSELS.      239 

hooks,  by  means  of  which  the  parasite  attaches  itseh'  to  the 
mucous  membrane  of  the  upper  portion  of  the  smaU  bowel,  and 
thus  withdraws  blood  by  suction.  In  addition  to  anemia,  with 
dyspnea,  edema,  wasting,  and  debility,  there  may  be  colicky 
abdominal  pains  and  diarrhea.  The  oval  eggs  appear  in  the 
stools.     Infection  takes  place  through  drinking-water. 


Distomiasis. 

What  is  distomiasis  ? 

Distomiasis  is  a  condition  due  to  the  presence  in  various 
structures  of  the  different  varieties  of  distomata,  trematode 
sucking-worms. 

The  distoma  hepaticum  is  a  liver-fluke,  about  1  inch  long  and 
^  inch  wide,  that  finds  its  way  into  the  biliary  passages,  the 
inferior  vena  cava  and  the  intestine  especially  in  ruminants,  and 
rarely  in  man. 

The  distoma  lanceolatum  is  about  ^  inch  long  and  J  as  wide. 
It  also  is  found  in  the  biliary  passages,  but  is  not  common  in 
man. 

The  distoma  hxmatohimn  is  from  i^  to  f  inch  long,  with  a  ten- 
dency to  a  cylindrical  shape.  It  is  found  in  the  trunk  and 
branches  of  the  portal  vein,  the  splenic  vein,  the  mesenteric 
veins  and  the  vessels  of  the  rectum  and  the  bladder.  The  ova 
penetrate  the  mucous  and  submucous  membranes  of  the  tubes, 
the  bladder,  the  rectum,  at  times  the  liver,  the  lungs,  the  kid- 
neys and  the  prostate,  giving  rise  to  inflammation,  ulceration, 
etc.  The  disease  is  common  in  Egypt  and  Abyssinia  in  both 
monkeys  and  man. 


Occlusion  of  the  Mesenteric  Vessels. 

What  are  the  clinical  features  of  occlusion  of  the  mesenteric 
vessels  ? 
Thrombosis  or  embolism  of  the  mesenteric  arteries  or  veins 


240 


ESSENTIALS    OP    DIAGNOSIS, 


may  arise  from  various  causes,  such  as  valvular  disease  of  the 
heart,  atheroma  or  inflammation  of  the  vessels,  arteriosclerosis, 
etc.  The  resulting  symptoms  vary  somewhat  with  the  rapidity 
of  occurrence  of  the  disturbance.  They  may  simulate  intestinal 
obstruction  and  consist  in  severe  abdominal  pain,  wi oh  vomiting 
that  may  become  stercoraceous  or  bloody,  tympanites  and  signs 
of  collapse.  There  may,  however,  be  diarrhea  with  bloody 
stools.  A  tumor  may  sometimes  be  detected  upon  palpation. 
The  bowel  undergoes  ulceration  or  gangrene. 


Oxyuris  Vermicularis, 

What  are  the  characteristics  of  the  oxyuris  vermicularis  ? 

Oxyures  vermiculares,  seat-worms,  thread- worms,  or  spool-worms, 
are  from  one-eighth  to  one-half  of  an  inch  long.  They  infest 
the  large  intestine,  especially  the  rectum.  The  worms  find 
their  way  out  of  the  anus,  and  give  rise  to  intense  itching. 

Fig.  28. 


1,  Female;   2,  males.  Ovum,  magulfied. 

Oxyuris  vermicularis,  natural  size  (Vierordt). 

Sometimes  they  gain  access  to  the  vagina,  and  occasion  un- 
pleasant symptoms.  The  parasites  may  be  present  in  the 
bowel  in  large  numbers  ;  they  are  often  found  in  the  stools  in 
tangled  masses,  resembling  bunches  of  thread.  Infection  takes 
place  probably  through  drinking-water  or  green  vegetables. 


ACUTE   PERITONITIS.  241 


Acute  Peritonitis. 

What  are  the  symptoms  of  acute  peritonitis  ? 

Acute  peritonitis  arises  from  the  activity  of  irritants  either 
conveyed  through  the  blood  or  resulting  from  local  disease.  It 
may  thus  be  caused  by  nephritis,  rheumatism,  tuberculosis, 
other  infectious  diseases,  inflammatory,  ulcerative  or  suppura- 
tive processes  in  any  of  the  abdominal  viscera,  traumatism  and 
oi:>erative  procedures. 

Acute  peritonitis  may  be  local  or  general ;  it  may  be  fibrinous, 
sero-fibrinous,  purulent,  putrid,  hemorrhagic  or  dry.  It  is  attended 
with  acute  abdominal  pain,  tympanites,  nausea,  vomiting,  con- 
stipation, considerable  elevation  of  temperature  and  other  febrile 
manifestations.  The  pulse  is  small,  rapid  and  tense — "wiry." 
The  face  is  drawn ;   the  expression  anxious. 

The  breathing  is  shallow,  rapid,  and  thoracic.  The  abdominal 
pain  and  tenderness  are  so  intense  that  the  patient  shrinks  from 
the  slightest  movement,  and  complains  of  the  lightest  covering. 
The  legs  and  thighs  are  drawn  up  in  flexion,  to  relax  the  ab- 
dominal parietes.  The  surface  of  the  body  may  be  covered 
with  a  cold  sweat  and  collapse  may  ensue.  Effusion  may  take 
place  or  adhesions  form  among  the  structures  in  the  peritoneal 
cavity.  Should  pus  form,  there  are  repeated  rigors  and  hectic 
fever.  If  the  inflammation  is  putrid,  death  speedily  takes  place 
amid  the  symptoms  of  profound  intoxication. 

How  are  acute  gastritis  and  acute  peritonitis  to  be  distin- 
guished from  one  another  ? 

Xausea,  vomiting,  constipation,  headache,  abdominal  pain 
and  tenderness,  and  febrile  symptoms  attend  both  acute  gastritis 
and  acute  peritonitis.  In  the  former,  however,  the  vomiting 
occurs  earlier  and  is  more  aggravated  than  in  the  latter,  and 
the  vomited  matter  may  contain  blood.  In  peritonitis,  the  ab- 
dominal pain  and  tenderness  are  not  confined  to  the  epigastrium, 
but  are  more  extensive  and  more  intense  than  in  gastritis,  while 
abdominal  distention  is  more  decided.  A  cause  will  be  obvious 
for  an  acute  gastritis  sufficiently  intense  to  simulate  peritonitis^ 
the  symptoms  of  which  are  relatively  the  more  profound. 

16 


242  ESSENTIALS    OF    DIAGNOSIS. 

How  are  acute  peritonitis  and  acute  enteritis  to  be  differ- 
entiated ? 

The  pain  of  enteritis  is  colicky  ;  that  of  peritonitis,  lancinat- 
ing. Tenderness  is  greater  and  more  general  in  peritonitis  than 
in  enteritis.  Diarrhea  is  common  in  enteritis ;  constipation  is 
the  rule  in  peritonitis.  Nausea  and  vomiting  are  more  decided 
in  peritonitis  than  in  enteritis.  Effusion  occurs  in  peritonitis, 
not  in  enteritis.  The  constitutional  disturbance  of  peritonitis 
is  comparatively  more  profound  than  that  of  enteritis.  Rigors 
and  fluctuating  temperature  are  suggestive  of  peritonitis.  The 
cause  of  peritonitis  is  sometimes  obvious  in  the  history  of  the 
case,  or  discoverable  upon  vaginal  or  other  examination. 

How  are  acute  intestinal  obstruction  and  acute  peritonitis  to 
be  differentiated  ? 

Constipation  attends  both  acute  peritonitis  and  acute  in- 
testinal obstruction  ;  it  may  yield  in  the  one,  but  it  is  insuperable 
in  the  other.  Prior  to  the  acute  symptoms  of  obstruction  there 
may  have  been  small,  liquid  evacuations,  but,  when  the  symp- 
toms of  obstruction  have  set  in,  constipation  is  absolute.  The 
vomiting  of  acute  peritonitis  does  not  present  any  unusual  feat- 
ures ;  that  of  intestinal  obstruction  soon  becomes  stercoraceous. 
The  pain  of  obstruction  is  colicky  ;  that  of  peritonitis  is  sharp 
and  lancinating.  The  exquisite  abdominal  tenderness  of  peri- 
tonitis is  not  encountered  in  obstruction.  When  obstruction 
exists,  the  rolling  of  the  intestines  may  be  apparent  to  the  eye 
or  to  the  palpating  hand.  Peritonitis  occasions  paralysis  of  the 
bowel.  The  febrile  symptoms  of  peritonitis  are  wanting  in  un- 
complicated obstruction. 

Inquiry  and  physical  examination  may  elicit  one  of  the  known 
causes  of  peritonitis  or  of  obstruction  respectively. 

How  are  acute  peritonitis  and  intestinal  colic  to  be  differenti- 
ated? 

Acute  peritonitis  and  intestinal  colic  have  pain  in  common  ; 
the  latter,  however,  is  unattended  with  febrile  manifestations. 

The  pain  of  colic  is  inconstant  and  is  relieved  by  frictions  ; 
in  peritonitis  the  pain  persists  and  is  intensified  by  the  slightest 
touch. 


CHRONIC    PERITONITIS.  2-43 

Colic,  as  a  rule,  is  symptomatic,  and  its  cause  is  to  be  ascer- 
tained upon  careful  search.  A  blue  line  on  the  gums  would 
indicate  lead-poisoning. 

How  is  subacute  rheumatism  involving  the  muscles  of  the  wall 
of  the  abdomen  to  be  distinguished  from  acute  peri- 
tonitis ? 

The  pain  of  rheumatism  is  not  so  severe  as  that  of  peritonitis  ; 
nor  is  it  as  constant  ;  nor  does  it  give  rise  to  symptoms  of  gastro- 
intestinal derangement  ;  and  it  is  not  attended  with  febrile 
manifestations  ;  while  in  addition  there  are  other  evidences 
and  a  history  of  exposure  to  influences  productive  of  subacute 
rheumatism. 

Chronic  Peritonitis. 

What  are  the  symptoms  of  chronic  peritonitis  ? 

Chronic  inflammation  of  the  peritoneum  may  be  the  sequel  of  an 
acute  attack  ;  it  may  be  insidious  in  development.  It  is  com- 
monly a  result  of  persistent  irritation,  such  as  may  depend  upon 
the  presence  of  new-growths,  carcinomatous,  sarcomatous  or 
tuberculous,  or  upon  chronic  inflammation  of  the  abdominal  or 
pelvic  viscera. 

Adhesions  form  between  adjacent  viscera  and  fluid  collects  in 
the  abdominal  cavity.  Paroxysmal  attacks  of  pain  occur.  The 
abdomen  is  distended.     There  may  be  nausea  and  vomiting. 

The  action  of  the  intestines  is  interfered  with  and  constipa- 
tion usually  results.  In  tuberculous  cases,  with  concomitant 
ulceration  of  the  intestine,  there  may  be  intercurrent  or  con- 
tinuous diarrhea.  In  proportion  to  the  chronicity  of  the  attack 
the  omentum  is  found  indurated  and  rolled  up  close  to  its  attach- 
ment to  the  stomach,  the  mesentery  is  shortened  and  the  lumen 
of  the  bowel  is  narrowed,  producing  visible  and  palpable  distor- 
tions and  prominences. 

There  is  commonly  more  or  less  fever,  sometimes  hectic,  espe- 
cially if  the  efl'usion  be  purulent.  Sometimes,  particularly  in 
tuberculous  disease,  there  are  recurrent  febrile  exacerbations. 
In  anv  case  there  occur  gradual  emaciation  and  loss  of  strenrrth. 


244  ESSENTIALS    OF    DIAGNOSIS. 

breathlessness,  edema  of  the  lower  extremities ;  spontaneous 
recovery  sometimes  happens,  but  as  a  rule,  unless  relief  be 
given,  surgically  or  medicinally,  death  ensues.  The  cases  are 
often  protracted. 

Malignant  disease  and  tuberculosis  of  the  peritoneum  are  most 
frequently  associated  with  similar  conditions  in  other  structures. 

How  are  chronic  peritonitis  and  malignant  disease  of  the  liver 
to  be  differentiated  ? 

Malignant  disease  of  the  liver,  like  chronic  peritonitis,  may 
give  rise  to  a  tumor  in  the  upper  portion  of  the  abdomen,  and 
to  ascites  ;  but  the  physical  signs  of  enlargement  fuse  with 
those  that  normally  belong  to  the  liver  ;  while  the  percussion- 
dulness  dependent  upon  an  omentum  rolled  up  and  contracted 
by  chronic  disease  is  separated  from  the  hepatic  dulness  by  an 
area  ot  tympanitic  resonance. 

Tabes  Mesenterica. 

What  are  the  symptoms  of  tabes  mesenterica  ? 

In  predisposed  children  the  glands  of  the  mesentery  some- 
times become  tuberculous,  and  there  occur  derangement  of 
health,  anemia,  and  wasting.  On  palpation  it  may  be  possible  to 
detect  the  enlarged  glands.  In  other  respects,  the  symptoms  are 
like  those  of  subacute  peritonitis  and  chronic  enteritis.  There  is 
much  confusion  and  dispute  concerning  the  existence  of  a  non- 
tuberculous  tabes  mesenterica,  of  which  the  jDrincipal  objective 
symptom  is  the  tumid  abdomen. 

THE  LIVER. 

What  are  the  normal  limits  of  the  liver  as  determined  by 
physical  examination  ? 

Under  normal  conditions  the  area  of  hepatic  percussion-dul- 
ness  (Figs.  29  and  30)  is  included  between  the  sixth  rib  on  the 
right,  in  the  nipple  line,  the  lower  margin  of  the  sixth  rib 
on  the  right  in  the  axilla,  and  the  tenth  rib  posteriorly  on  the 
right,  on  the  one  hand,  and  the  inferior  border  of  the  right 


FLOATING    LIVER. 
Fig.  29. 


245 


The  relatioBS  of  the  heart,  hmgs,  lirer,  stomach  and  spleen,  as  seen  from  the 
front  (Weil).  The  deeply-shaded  areas  represent  the  portions  of  the  heart,  liver 
and  spleen  not  covered  by  the  lungs  ;  the  lightly-shaded  areas  represent  portions 
covered  by  the  lungs,  b,  c,d,  boundary  between  lung  and  heart ;  e  f,  lower  bound- 
aries of  lungs  ;  g  h,  upper  boundaries  of  lungs ;  Z,  lower  limit  of  hepatic  dulness  ; 
m,  area  of  splenic  dulness;  ?i,  greater  curvature  of  stomach;  j>,  upper  limit  of 
deep  hepatic  dulness. 

costal  arch  on  the  other.  The  left  lobe  extends  into  the  left 
hypochondrium  and  the  dulness  to  which  it  gives  rise  is  practi- 
cally inseparable  from  the  cardiac  percussion-dulness. 


Floating  Liver. 

To  what  symptoms  does  a  floating  liver  give  rise  ? 

Occasionally  the  coronar}^  ligament  of  the  liver  becomes  length- 
ened and  the  organ  acquires  an  abnormal  freedom  of  movement. 


246 


ESSENTIALS    OF    DIAGNOSIS. 
Fig.  30. 


Showing  the  relations  of  the  lungs,  liver,  spleen  and  kidneys,  as  seen  from  hehind 
(Weil-Luschka).  The  deeply-shaded  areas  represent  portions  of  the  liver  and 
spleen  not  covered  by  the  lungs ;  the  lightly-shaded  areas  represent  portions 
covered  by  the  lungs,  a  b,  lower  border  of  the  lungs;  c  d,  boundaries  of  comple- 
mentary pleural  spaces  ;  e/ (7,  divisions  between  lobes  of  lungs;  i,  lower  margin 
of  liver. 

That  such  an  unusual  tumor  in  the  abdomen  is  the  hver  is  de- 
termined by  the  size  and  conformation  of  the  organ,  by  the  per- 
cussion-resonance in  the  normal  region  of  the  liver  and  by  the 
absence  of  the  phenomena  of  malignant  disease. 

Congestion  of  the  Liver. 

What  are  the  symptoms  of  congestion  of  the  liver  ? 

Congestion  of  the  liver  results  from  derangement  of  the  circula- 
tion dependent  upon  disease  of  the  heart  or  lungs,  or  upon  com- 


ACUTE    HEPATITIS.  247 

pression  of  the  hepatic  vessels  ;  it  may  result  from  constant  irri- 
tation of  the  hepatic  cells  by  improper,  and  especially  stimulating, 
articles  of  diet ;  it  is  wont  to  occur  in  those  of  inactive  and  seden- 
tary habits.  The  condition  is  manifested  by  a  sense  of  weight 
and  dull  pain  in  the  right  hypochoudrium,  pain  at  the  right 
shoulder,  headache  and  vertigo.  The  appetite  is  impaired;  the 
tongue  is  coated  ;  there  are  nausea  and  vomiting  ;  the  digestion 
is  deranged  ;  the  6oit"e7sare  constipated  ;  the  sA-m  and  conjunctiva 
may  present  a  yellowish  tinge  ;  hemorrhoids  frequently  develop  ; 
there  is,  sometimes,  mental  depression  or  irritability  of  tem- 
per ;  the  heart  may  be  irritable,  as  manifested  by  palpitation. 
The  urine  may  contain  bile-pigment  and  an  excess  of  urates. 

Acute  Hepatitis. 

What  are  the  symptoms  of  acute  hepatitis  ? 

Acute  hepatitis  is  essentially  a  disease  of  tropical  climates. 
It  may  also  occur  in  association  with  dysentery  and  other  in- 
fectious diseases. 

It  is  manifested  by  pain  in  the  right  hypochondrium,  febrile 
symptoms  and  possibly  slight  Jaundice.  The  apjpeiite  is  im- 
paired, and  there  may  be  nausea  and  vomiting.  Abscess  is 
a  not  uncommon  sequel  of  inflammation  of  the  liver. 

How  is  the  malarial  cachexia  to  be  distinguished  from  acute 
hepatitis  ? 
As  a  sequel  of  chronic  malarial  poisoning,  the  liver  and  the 
spleen  become  crowded  with  pigment  and  undergo  enlarge- 
ment. There  may  be  slight  intermittent  fever  ;  the  fever  of 
hepatitis  is  continuous  and  not  periodic.  In  the  malarial 
cachexia  the  complexion  is  sallow,  not  jaundiced,  as  it  may  be 
in  hepatitis.  In  the  malarial  cachexia,  too,  plasmodia  are  to 
be  found  in  the  blood. 

How  are  acute  hepatitis  and  portal  phlebitis  to  be  differentiated? 

Portal  phlebitis  may  develop  in  the  course  of  infectious  dis- 
eases or  of  pyemia  ;  it  may  also  result  b}'-  extension  from 
adjacent  disease.  It  is  attended  by  pain  in  the  right  hypo- 
chondrium, by  enlargement  of  the  liver,  by  distention  of  the 


248  ESSENTIALS    OF    DIAGNOSIS. 

veins  of  the  abdominal  wall,  by  ascites,  by  enlargement  of  the 
spleen  and  by  diarrhea.  Gastric  or  intestinal  hemorrhage  may 
occur.  When  suppuration  takes  place,  there  are  recurring 
chills  and  fever,  with  wasting  and  debility.  Enlargement  of 
the  spleen,  distention  of  the  abdominal  veins  and  gastric  and 
intestinal  hemorrhage  are  not  a  part  of  acute  hepatitis. 

Acute  Yellow  Atrophy  of  the  Liver. 

What  are  the  symptoms  of  acute  yellow  atrophy  of  the  liver  ? 

The  etiology  of  acute  yellow  atrophy  of  the  liver  is  obscure. 
The  disease  is  more  common  in  females  than  in  males,  and  in 
young  adults  than  in  others  ;  it  sometimes  appears  in  the 
course  of  pregnancy  ;  at  other  times,  in  conjunction  with  pro- 
found emotion.  After  death,  the  liver  is  found  to  be  much  re- 
duced in  size  and  weight ;  in  places  it  presents  areas  of  reddish, 
purplish  and  yellowish  discoloration,  in  the  midst  of  which  the 
hepatic  cells  are  replaced  by  granules  and  oil-globules.  By 
some  the  condition  is  said  to  b6  a  parenchymatous  inflammation 
of  the  liver. 

The  onset  of  the  more  grave  symptoms  may,  for  a  few  days 
or  weeks,  have  been  preceded  by  jaundice.  This  has  even  been 
associated  in  rare  instances  with  enlargement  of  the  area  of 
hepatic  percussion-flatness.  Commonly,  there  are  soon  added 
headache,  intolerance  of  light,  delirium,  stupor,  convulsions 
and  coma.  The  tongue  is  dry  and  coated  ;  there  are  nausea 
and  vomiting.  Hemorrhages  from  the  mucous  surfaces  often 
occur,  and  subcutaneous  petechige  appear.  The  area  of  hepatic 
percussion-dulness  progressively  diminishes ;  the  abdomen  be- 
comes distended.  The  urine  may  be  scarcely  discolored  ;  it 
contains  leucin  and  tyrosin,  and  sometimes  albumin  ;  it  is  defi- 
cient in  urea,  uric  acid,  chlorids,  phosphates  and  sulphates ;  it 
may  contain  an  excess  of  ammonia.  There  may  be  chills  and 
irregular  fever,  sometimes  high  ;  usually,  however,  there  is  but 
slight  elevation  of  temperature ;  and  in  most  cases  the  tem- 
perature is  at  some  time  subnormal.  The  disease  rarely  lasts 
longer  than  a  week ;  it  usually  terminates  fatally. 


ACUTE    YELLOW    ATROPHY    OF    THE    LIVER.       249 

How  are  acute  yellow  atrophy  of  the  liver  and  typhoid  fever  to 
be  differentiated  ? 

Typhoid  fever  is  a  disease  lasting  three  or  four  weeks  ;  re- 
covery is  common.  The  active  stage  of  acute  yellow  atrophy 
rarely  lasts  longer  than  a  week  ;  the  termination  is  usually  fatal. 
There  is  but  slight  or  very  irregular  fever  in  acute  yellow  atrophy 
and  nearly  always  a  tendency  to  subnormal  temperature  ;  the 
course  of  typhoid  fever  is  decidedly  febrile  and  typical.  Diar- 
rhea is  common  in  typhoid  fever  ;  constipation,  in  acute  3'ellow 
atrophy.  The  size  of  the  liver  becomes  much  reduced  in  acute 
atrophy  ;  it  is  unchanged  or  increased  in  typhoid  fever.  Rose- 
spots  are  wanting  in  acute  atrophy,  in  which  there  may  be  pe- 
techite.  Jaundice  is  invariable  in  acute  atrophy ;  rare  in 
typhoid  fever.  The  cerebral  symptoms  are  more  decided  in  the 
hepatic  disease  than  in  the  infective  fever.  The  presence  of 
leucin  and  tyrosin  and  the  deficiency  of  urea,  uric  acid,  chlo- 
rides, phosphates  and  sulphates  in  the  urine  are  characteristic 
of  acute  yellow  atrophy;  while  the  blood  and  the  urine  of 
typhoid  fever  exhibit  distinctive  reactions. 

How  are  acute  yellow  atrophy  of  the  liver  and  phosphorus- 
poisoning  to  he  differentiated  ? 

The  symptoms  occasioned  by  poisoning  with  phosphorus 
closely  resemble  those  of  acute  yellow  atrophy  of  the  liver. 
Phosphorus-poisoning,  however,  usually  sets  in  with  vomiting 
and  purging,  to  which  the  subsequent  manifestations  succeed  ; 
there  is  sometimes  necrotic  disease  of  the  inferior  maxillary 
bone.  The  alkalinity  of  the  blood  may  be  diminished  and  the 
nuniber  of  red  cells  increased.  The  first  symptom  of  acute 
yellow  atrophy  of  the  liver  is  jaundice.  In  phosphorus-poison- 
ing the  liver  is  enlarged  prior  to  becoming  smaller ;  the  diminu- 
tion in  the  size  of  the  liver  in  acute  yellow  atrophy  is  progressive 
from  the  onset  of  active  symptoms,  though  the  organ  may  have 
been  enlarged  previously.  Colicky  abdominal  pains  usually 
attend  phosphorus-poisoning,  of  which  it  may  be  possible  to 
elicit  a  history.  The  anatomic  lesion  of  acute  yellow  atrophy 
is  a  parenchymatous  hepatitis ;  of  phosphorus-poisoning,  a  fatty 
degeneration  of  the  liver. 


250  ESSENTIALS   OF    DIAGNOSIS. 

Abscess  of  the  Liver. 

What  are  the  symptoms  of  abscess  of  the  liver  ? 

Abscess  of  the  liver  may  follow  traumatism  or  acute  hepatitis; 
it  may  result  from  the  activity  of  pyogenic  organisms  introduced 
into  the  structure  of  the  organ  in  the  course  of  inflammation 
of  the  biliary  ducts,  or  of  ulcerative  processes  in  the  distribution 
of  the  tributaries  of  the  portal  vein,  or  as  a  part  of  a  general 
pyemia.  When  the  suppuration  is  dependent  upon  trauma- 
tism, hepatitis  or  ulceration,  but  a  single  abscess  usually 
develops ;  in  cases  of  pyemia,  there  may  be  multiple  abscesses, 
not  only  in  the  liver,  but  also  elsewhere.  Dysentery  is  a  com- 
mon cause  of  hepatic  abscess.  When  the  two  are  associated,  the 
amoeba  coli  may  be  found  both  in  the  stools  and  in  the  abscess 
or  its  walls.  The  right  lobe  suffers  more  commonly  than  the 
left.  As  a  result  of  the  inflammation  associated  with  the 
development  of  an  abscess,  the  liver  becomes  enlarged  and 
tender,  the  enlargement  tending  upward"  and  being  detectable 
by  palpation  and  percussion.  There  is  pain  over  the  liver  and 
at  the  right  shoulder.  The  tissues  over  the  liver  are  often 
edematous.  The  right  hypochondrium  may  be  exquisitely 
tender.  Repeated  rigors  may  occur ;  there  may  be  periodic 
exacerbations  of  temperature,  followed  by  copious  sweats. 
Slight  jaundice  may  develop,  but  it  is  often  absent.  There 
may  be  nausea,  vomiting  and  diarrhea.  The  number  of  color- 
less blood-corpuscles  is  increased.  Hiccough,  cough  and 
dyspnea  may  result  from  pressure  upoiribhe  diaphragm,  and 
pleurisy,  with  the  symptoms  and  physical  signs  denoting  a 
rapid  eflusion,  may  result  from  extension  of  the  inflammation 
or  conveyance  of  the  infection.  When  the  abscess  is  superficial, 
a  fluctuating  tumor  may  be  detectable  in  the  right  hypochon- 
drium. The  abscess  may  rupture  into  the  pleural  cavity  or 
into  the  peritoneum,  with  a  fatal  termination  ;  or  the  pus  may 
make  its  exit  through  the  abdominal  wall,  or  even  into  the 
intestines.  A  hepatic  abscess  may  be  evacuated  through  the 
bronchial  tubes,  the  fluid  evacuated  presenting  the  reddish- 
brown  appearance  of  anchovy  sauce.  Death  may  result  from 
septic  poisoning  or  from  exhaustion. 


ABSCESS   OP   THE    LIVER.  251 

How  are  abscess  of  the  liver  and  occlusion  of  the  biliary  pas- 
sages to  be  differentiated  ? 

If  the  common  bile-duct  is  obstructed,  bile  accumulates  in 
the  gall-bladder  and  in  the  radicles  of  the  hepatic  ducts,  the 
liver  becomes  enlarged,  and  jaundice,  rigors,  fever  and  sweats 
appear.     The  stools  are  pale. 

If  the  cystic  duct  is  occluded,  there  is  no  jaundice  and  the 
stools  are  not  discolored.  In  both  instances,  the  gall-bladder 
becomes  distended  with  fluid  and  constitutes  a  fluctuating 
tumor,  which  may  simulate  an  abscess.  The  difierentiation 
depends  upon  the  fact  of  the  tumor  occupying  the  situation  of 
the  gall-bladder,  upon  a  knowledge  of  the  existence  of  a  cause 
of  biliary  obstruction,  such  as  a  calculus  or  a  neoplasm,  and 
upon  the  absence  of  a  cause  of  abscess  ;  nor  is  an  abscess  likely 
to  occasion  jaundice. 

How  are  abscess  of  the  liver  and  carcinoma  of  the  liver  to  be 
differentiated  ? 

Medullary  carcinoma  may  give  rise  to  a  sort  of  fluctuation 
on  palpation,  but  beyond  this  and  the  enlargement  of  the  liver, 
the  symptoms  uifier  radically  from  those  of  abscess.  In  cases 
of  carcinoma,  chills,  fever  and  sweats  do  not  occur ;  but  there 
is  distinct  cachexia,  perhaps  with  nodules  in  other  situations. 

How  is  actinomycosis  of  the  liver  to  be  distinguished  from 
abscess  of  the  liver  ? 

Actinomycosis  is  dependent  upon  the  presence  of  a  special 
fungus,  which  usually  gains  entrance  through  an  abrasion  of 
the  surface,  and  may  be  disseminated  by  the  blood-stream. 

The  irritation  caused  by  the  presence  of  the  fungus,  or  per- 
haps by  some  product  of  its  metabolism,  is  followed  by  inflamma- 
tion and  suppuration,  so  that  the  conditions  of  abscess  are  repro- 
duced, and  in  that  sense  there  is  no  discrimination  to  be  made. 

The  diagnosis  depends  upon  a  knowledge  of  infection  or  of 
the  existence  of  the  disease  at  the  original  site  of  entrance,  or 
the  discovery  of  the  ray-fungus  (actinomyces)  in  the  pus. 


252  ESSENTIALS    OF   DIAGNOSIS. 

Interstitial  Hepatitis— Cirrhosis  of  the  Liver. 

What  are  the  symptoms  of  interstitial  hepatitis,  also  called 
sclerosis  or  cirrhosis  of  the  liver  ? 

When  irritating  matters  are  in  constant  circulation  in  the 
blood-current,  especially  in  the  portal  stream,  the  interstitial 
connective-tissue  of  the  liver  slowly  undergoes  hyperplasia,  to 
the  consequent  detriment  of  the  parenchymatous  structures. 
The  rapidity  of  the  process  depends  upon  the  intensity  of  the 
irritation.  When  the  increase  of  connective  tissue  has  reached 
its  height,  contraction  sets  in  and  the  liver-cells  suffer  still  more. 
The  organ,  at  first  irregularly,  perhaps  nodularly,  enlarged,  now 
becomes  diminished  in  size.  This  is  the  condition  of  cirrhosis. 
The  different  stages  are  sometimes  respectively  called  hypertro- 
phic cirrhosis  and  atrophic  cirrhosis.  In  many  cases  the  enlarge- 
ment persists,  notwithstanding  extensive  des-truction  of  the 
secreting  structures.  In  other  cases  the  hepatic  percussion- 
dulness  and  palpation-area  are  apparently  diminished  from  the 
first.  In  the  early  stages  of  the  disease  the  symptoms  are  in- 
conspicuous ;  there  may  be  manifestations  of  derangement  of 
the  gastro-intestinal  system.  As  the  contraction  becomes  more 
marked,  however,  there  appear  evidences  of  interference  with 
the  functions  of  the  liver.  Ascites  develops  ;  the  superficial 
veins  of  the  abdomen  become  enlarged  and  prominent ;  this 
may  be  especially  marked  in  the  neighborhood  of  the  umbilicus, 
giving  rise  to  the  so-called  Caput  Medusae;  small  networks  of 
venules  appear  at  various  parts  of  the  surface  of  the  body  ; 
hemorrhoids  form  ;  hemorrhages  may  take  place  from  the  nose 
and  stomach  ;  the  skin  assumes  a  pallid,  clayey  hue  ;  and  ulti- 
mately jaundice  appears.  The  spleen  is  often  enlarged.  Ver- 
tigo is  not  rare.  Late  in  the  disease,  drowsiness  and  coma  may 
develop.  Excessive  indulgence  in  alcohol  is  the  most  common 
cause  of  cirrhosis  of  the  liver.  This  variety  of  cirrhosis  has 
been  designated  portal. 

Under  other  circumstances  the  hj'perplasia  involves  more 
particularly  the  distribution  of  the  biliary  radicles,  and  the  liver 
maintains  its  enlarged  size.  In  this  variety  of  cirrhosis  jaundice 
appears  early,  while  ascites  occurs  late  if  at  all.     The  affection 


FATTY    LIVER.  253 

is  of  long  duration,  and  attended  with  pain  in  the  right  hypo- 
chondrium,  recurring  in  attacks.  I'he  s])leen  is  enlarged  and 
hard.    This  variety  of  cirrhosis  has  been  designated  biliary. 

Fatty  Liver. 

What  are  the  symptoms  of  fatty  liver  ? 

The  liver  may  undergo /af ^7/  infiltration  ov  fatty  r)ietamorphosis, 
A  temporary  accumulation  of  f\it  in  the  liver  occurs  under 
normal  conditions  after  the  ingestion  of  food  rich  in  hydrocar- 
bons. When,  from  any  cause,  oxidation  becomes  deficient,  this 
fatt}'^  infiltration  may  become  permanent  and  excessive,  the 
more  especially  if,  at  the  same  time,  immoderate  eating  or 
drinking  is  indulged  in.  Thus  the  condition  is  found  in  the 
indolent,  in  gourmands,  in  the  obese,  in  the  subjects  of  pul- 
monary tuberculosis  and  in  drunkards. 

Drunkards,  however,  are  more  liable  to  true  fatty  raetamor' 
phosis,  the  liver-cells  in  circumscribed  or  extensive  areas  un- 
dergoing oily  degeneration,  a  condition  that  may  likewise  occur 
in  wasting  diseases,  or  as  an  apparent  result  of  protracted  dis- 
charges, or  of  blood-changes,  in  pyemia,  infectious  diseases,  or 
other  morbid  states  accompanied  by  protracted  high  tempera- 
ture. It  is  sometimes  a  part  of  the  degenerative  processes  of 
old  age.  It  may  accompany  carcinoma,  cirrhosis  and  amyloid 
degeneration  of  the  liver. 

The  symptoms  are  not  early  obtrusive.  The  area  of  hepatic 
percussion-dulness  is  increased,  and  to  palpation  the  organ 
seems  smooth  and  rounded,  perhaps  soft  and  doughy.  The 
skin  may  feel  greasy  or  velvety,  and  is  sometimes  smooth  and 
glistening;  it  may  be  pale  or  flushed.  Hemorrhoids  are  not 
infrequent.  Jaundice  is  uncommon  ;  there  is  no  pain  ;  ascites 
is  rare.  Diarrhea  is  the  most  constant  symptom,  and  the  least 
indiscretion  in  diet  may  provoke  gastro-intestinal  catarrh.  In 
the  more  advanced  stages  anemia,  hydremia,  dyspnea  and 
patent  signs  of  failure  of  hepatic  function  appear. 


254  ESSENTIALS    OF    DIAGNOSIS. 

Amyloid  Disease  of  the  Liver. 

What  are  the  symptoms  of  amyloid,  waxy  or  lardaceous  disease 
of  the  liver  ? 
When  the  liver  undergoes  amyloid  degeneration,  other  organs, 
such  as  the  spleen,  the  kidneys,  perhaps,  also,  the  stomach  and 
the  intestines,  are  likewise  involved,  either  simultaneously 
or  consecutively.  The  liver  is  smoothly  and  often  enormously 
enlarged  ;  digestion  is  impaired  ;  there  may  be  persistent  diar- 
rhea. Pain,  jaundice  and  ascites  are  uncommon.  Isolated  dis- 
ease of  the  liver  usually  escapes  detection.  The  process  is 
chronic.  Amyloid  degeneration  is  a  sequel  of  syphilis,  of  tuber- 
culosis, of  suppuration,  of  bone-disease. 

How  are  amyloid  disease  and  cirrhosis  of  the  liver  to  be  differ- 
entiated ? 

The  liver  is  enlarged  in  both  amyloid  disease  and  cirrhosis  of 
the  liver  ;  the  enlargement  is  persistent  in  the  one,  replaced  by 
contraction  in  the  other.  The  amyloid  liver  is  smooth,  the  cir- 
rhotic liver  usually  irregular.  Cirrhosis  is  attended  with  ascites 
and  jaundice,  while  amyloid  disease,  as  a  rule,  is  not.  In  amy- 
loid disease,  there  is  a  history  of  syphilis,  of  tuberculosis,  of 
suppuration  or  of  bone-disease  ;  in  cirrhosis,  there  is  in  most 
cases  a  history  of  alcoholism.  With  amyloid  disease  of  the  liver 
is  usually  associated  amyloid  disease  of  the  kidney,  occasioning 
the  presence  of  albumin  and  tube-casts  in  the  urine.  The  tube- 
casts  will  sometimes  give  a  characteristic  reaction  with  iodine. 

Carcinoma  of  the  Liver. 

What  are  the  symptoms  of  carcinoma  of  the  liver  ? 

The  liver  is  a  frequent  seat  of  carcinoma,  which  may  be 
primary  or  secondar}'-.  Primary  carcinoma  of  the  liver  may  be 
massive,  nodular  or  cirrhotic ;  secondary  carcinoma  is  usually 
nodular.  In  its  incipiency  carcinoma  of  the  liver  may  escape 
detection.  Soon,  however,  there  is  unaccountable  loss  of  flesh, 
with  the  development  of  the  characteristic  cachexia.  The  liver 
is  noted  to  be  enlarged,  and  on  palpation  adventitious  nodules 


CARCINOMA   OP   THE   LIVER.  255 

may  be  felt  throiigli  the  abdoniinal  wall,  in  the  region  of  the 
right  hypochondrium.  Jaundice  is  uncommon,  unless  the  bili- 
ary passages  are  compressed.  The  abdomen  becomes  distended 
and  fluid  collects  in  the  peritoneal  cavity.  The  digestive 
derangement  becomes  marked.  Emaciation  progresses  and  the 
patient  becomes  reduced  to  the  lowest  degree.  There  is  often 
excruciating  lancinating  pain.  Tenderness  in  th  3  right  hypo- 
chondrium is  a  fairly  constant  attendant  of  car  jinoma  of  the 
liver. 

How  is  carcinoma  of  the  liver  to  be  distinguished  from  amyloid 
disease  of  the  liver  ? 

Emaciation  and  anemia  attend  both  carcinoma  and  amyloid 
disease  of  the  liver  ;  but  the  straw-colored  appearance  presented 
by  a  patient  with  the  carcinomatous  cachexia  is  wanting  in  the 
conditions  that  give  rise  to  am3'loid  disease.  Cases  of  carcinoma 
do  not  present  the  peculiar  distribution  of  amyloid  disease  in 
liver,  spleen,  kidneys  and  gastro-mtestinal  tract.  The  liver  is 
often  nodulated  when  carcinomatous ;  an  amyloid  liver  is 
always  smooth.  Pain  is  present  in  carcinoma,  absent  in  amj'loid 
disease.  A  history  of  congenital,  or  of  acquired  syphilis,  of 
tuberculosis,  or  the  presence  of  a  suppurating  focus  anj'where 
in  the  body  would  weigh  in  favor  of  amyloid  disease.  Amyloid 
disease  itself  is  not  immediately  fatal.  Life  is  not  likely  to  be 
prolonged  for  more  than  a  year  after  carcinoma  of  the  liver  has 
been  discovered. 

How  are  carcinoma  of  the  omentum  and  carcinoma  of  the  liver 
to  be  differentiated. 

When  carcinoma  develops  in  the  omentum,  this  structure 
becomes  shortened  and  rolled  up  beneath  its  attachments.  As 
a  consequence,  there  is  dulness  on  percussion,  and  evidences  of 
a  new-growth  on  palpation,  not  alone  in  the  right  hypochon- 
drium, but  in  the  epigastric  and  umbilical  regions,  and  in  the 
left  hypochondrium. 

Carcinoma  of  the  omentum  is  more  commonly  than  carcinoma 
of  the  liver  associated  with  ascites.  In  carcinoma  of  the  omen- 
tum the  symptoms  of  derangement  of  the  functions  of  the  liver 
are  wanting.   A  new-growth  of  the  liver  rises  and  falls  with  this 


256  ESSENTIALS    OF    DIAGNOSIS. 

organ  in  expiration  and  inspiration  ;   when  the   omentum  is 
involved  the  mass  is  fixed. 

How  are  carcinoma  of  the  stomach  and  carcinoma  of  the 
liver  to  he  differentiated? 
Carcinoma  of  the  stomach  and  carcinoma  of  the  liver  pre- 
sent man}^  symptoms  in  common  :  a  tumor  in  the  right  hypo- 
choudrium,  progressive  emaciation,  cachexia  and  secondary 
growths  ;  but  when  the  stomach  alone  is  involved  there  is  obsti- 
nate vomiting,  with  absence  of  evidence  of  hepatic  derangement"; 
while  if  the  liver  only  is  involved  ascites  is  common,  and  vomit- 
ing of  coffee-ground  material  is  lacking.  A  new-growth  of  the 
liver  will  rise  and  fall  with  this  organ  in  respiration  ;  a  gastric 
tumor  is  more  fixed.  The  percussion-dulness  yielded  by  a 
tumor  of  the  liver  merges  with  the  dulness  of  the  liver  ;  while 
the  dulness  of  a  tumor  of  the  stomach  may  be  separated  from 
the  hepatic  dulness  by  an  interval  of  tympanitic  resonance. 
Hepatic  and  gastric  carcinoma  not  infrequently  coexist. 


Hydatid  Cyst  of  the  Liver. 

To  what  symptoms  does  an  hydatid  cyst  of  the  liver  give  rise  ? 

A  small,  deeply-seated  hydatid  cyst  of  the  liver,  not  interfering 
with  the  function  of  other  parts,  may  give  no  sign.  When  the 
liver  is  the  seat  of  an  hydatid  cyst  in  an  accessible  situation,  the 
condition  may  be  recognized  by  the  presence  of  a  soft,  elastic, 
resistant,  fluctuating  tumor,  the  viscid  contents  of  which 
may,  on  percussion  and  palpation,  transmit  a  peculiar  thrill  or 
fremitus.  This  "purring  tremor,"  recalling  the  trembling  of  a 
bowl  of  jelly,  is  present  in  about  one-half  of  the  cases.  In 
addition,  there  may  be  pain  in  the  right  hypochondrium.  The 
presence  of  such  a  new-growth,  together  with  the  absence  of 
symptoms  of  profound  constitutional  disturbance,  distinguishes 
an  hydatid  cyst  from  a  malignant  growth  in  the  liver  and  its 
neighborhood. 

Pressure-signs  var}''  with  the  location  of  the  tumor.  A  cyst 
situated  near  the  hepatic  duct  or  common  bile-duct  may  cause 


HYDATID    CYST    OF    THE    LIVER.  257 

obstruction  and  fatal  jaundice  ;  pressure  on  the  portal  vein 
maj"^  cause  ascites  ;  jaundice  and  dropsy,  however,  are  not  usual. 
If  on  the  upper  surface  of  the  right  lobe,  the  cyst  will  push  up 
the  diaphragm,  giving  rise  to  dyspnea  and  cough.  The  heart 
may  be  displaced.  If  the  enlargement  takes  a  different  direc- 
tion, the  abdominal  viscera  may  be  encroached  upon.  There 
may  be  multiple  C3'sts. 

Retrogressive  changes  may  take  place  in  an  hydatid  cyst, 
attended  with  a  diminution  in  size.  The  contents  of  the  cyst 
may  be  evacuated  through  the  stomach,  bowel,  bronchial  tubes 
or  abdominal  wall,  or  into  the  abdominal  or  pleural  cavit3\ 

Spontaneous  evacuation  may  lead  to  recovery  or  it  may  cause 
inflammation  and  suppuration  of  the  invaded  organ  and  death 
result.  Sudden  death  may  happen  from  invasion  of  the  vena 
cava  or  of  the  pericardium.  When  retrogression  or  evacuation 
is  not  brought  about,  spontaneously  or  therapeutically,  gradual 
failure  and  death  may  occur  from  exhaustion,  or  from  septi- 
cemia. 

How  are  abscess  of  the  liver  and  hydatid  cyst  of  the  liver 
to  be  differentiated? 

An  hydatid  cyst  of  the  liver  is  ordinarily  w^anting  in  the 
constitutional  phenomena  of  hepatic  abscess  :  rigors,  fever, 
sweats,  emaciation.  Should  suppuration  take  place  an  abscess 
virtually  results.  Hydatid  cysts  are  insidious  in  onset,  slow  in 
development,  protracted  in  duration,  and  may  undergo  sponta- 
neous disappearance  ;  when  accessible  they  occasion  extensive 
percussion-dulness  and  a  peculiar  thrill  on  palpation.  An  he- 
patic abscess  may  be  insidious  in  onset,  but  it  soon  gives  rise 
to  decided  symptoms  ;  spontaneous  resolution  never  occurs,  and 
thrill  or  fremitus  is  wanting.  The  detection  of  echinococcus 
booklets  in  the  contents  of  an  hydatid  cyst,  and  of  amo^bge  coli 
in  the  pus  from  an  hepatic  abscess  may  in  each  case  be  regarded 
as  diagnostic. 

There  is  a  growing  tendency  to  regard  exploratory  puncture 
as  inconclusive  and  dangerous,  and  to  substitute  exploratory 
incision— the  latter  to  be  followed  if  necessary  by  immediate 
operation. 
17 


258  ESSENTIALS    OF    DIAGNOSIS. 

How  are  an  hydatid  cyst  of  the  liver  and  a  distended  gall- 
bladder to  be  differentiated  ? 

Distention  of  the  gall-bladder  is  usually  dependent  upon 
occlusion  of  the  common  bile-duct,  or  of  the  cystic  duct,  and  is 
commonly  associated  with  intense  jaundice  and  clay-colored 
stools.  Jaundice  is  exceptional  in  the  case  of  an  hydatid  cyst, 
and  the  action  of  the  bowels  is  not  necessarily  deranged.  A 
distended  gall-bladder  occupies  a  definite  situation  ;  an  hydatid 
cyst  may  be  seated  in  any  part  of  the  liver.  The  "purring 
tremor"  is  not  given  by  a  distended  gall-blader. 

Perihepatitis. 

What  are  the  clinical  features  of  chronic  inflammation  of  the 
capsule  of  the  liver,  or  perihepatitis  ? 
The  capsule  of  the  liver  may  become  thickened  as  a  result  of 
contiguous  inflammatory  processes,  such  as  pleuritis  and  hepa- 
titis, or  as  may  be  occasioned  by  a  gastric  ulcer.  Perihepatitis 
may  also  be  but  a  part  of  a  chronic  peritonitis.  The  liver  itself 
is  deformed,  and  may  be  diminished  in  size.  The  symptoms 
are  ill-defined.  Pain  and  tenderness  in  the  region  of  the  liver 
are  usually  present.  Ascites  develops.  The  kidneys  are  said 
usualh^  to  be  diseased,  so  that  the  urine  contains  albumin. 

How  are  chronic  perihepatitis  and  cirrhosis  of  the  liver  to  be 
differentiated  ? 
Cirrhosis  of  the  liver  and  perihepatitis  may  be  associated. 
Occurring  independently,  the  enlargement  or  the  diminution  in 
the  size  of  the  liver  and  the  jaiimiice  of  cirrhosis  are  likely  to  be 
wanting  in  perihepatitis  ;  while  the  presence  of  albumin  in  the 
urine  points  to  the  existence  of  perihepatitis. 

Cholangitis — Cholecystitis . 

What  are  the  symptoms  of  inflammation  of  the  bile-ducts  and 
gall-bladder  ? 

Inflammation  or  catarrh  of  the  bile-ducts  and  gall-bladder,  the 
most  common  cause  of  jaundice,  is  a  result  of  the  extension  of 


CHOLANGITIS  —  CHOLECYSTITIS.  259 

inflammation  or  catarrh  or  of  the  invasion  of  microbes  from  the 
duodenum  or  of  the  presence  of  biliary  calcuH. 

In  consequence  of  the  swelling  of  the  mucous  membrane,  the 
flow  of  bile  is  interfered  with  and  jaundice  results.  The  sur- 
face of  the  body  and  the  visible  mucous  membranes  assume  a 
yellowish  or  greenish  hue  ;  the  urine  is  similarly  discolored  ;  the 
stools  become  scanty  and  clay-colored.  The  saliva  may  be 
disc(ilored.  It  may  be  possible  to  palpate  the  enlarged  gall- 
l  ladder. 

There  is  pain  in  the  right  hypochondrium ;  the  liver  is  en- 
larged. The  action  of  the  heart  is  retarded,  and  the  respiratory 
frequency  is  lessened.  There  is  itching  of  the  skin.  The 
appetite  is  usually  impaired ;  the  tongue  is  coated ;  digestion  is 
enfeebled;  the  bowels  are  constipated.  Chills  and  irregular 
fever  or  transient  rise  of  temperature  may  occur. 

How  is  catarrhal  jaundice  to  be  distinguished  from  other 
forms  of  jaundice? 

Many  conditions  occasion  jaundice.  In  some,  as  in  catarrhal 
jaundice,  there  is  an  interference  with  the  discharge  of  bile  into 
the  intestine ;  in  others,  no  such  obstruction  can  be  detected. 
In  the  first  group  of  cases  belong  such  conditions  as  occlusion 
of  the  common  bile-duct  by  gall-stones,  or  parasites,  stricture 
or  obliteration  or  new-growths  of  the  duct,  compression  of  the 
common  bile-duct  by  enlarged  glands  or  by  neoplasms  or  as  a 
result  of  inflammation  and  thrombosis  of  the  portal  vein.  In 
the  second  group  belong  yellow  fever,  Weil's  disease,  the  intense 
forms  of  malarial  fever,  acute  yellow  atrophy  of  the  liver  and 
cirrhosis  of  the  liver. 

When  the  common  bile-duct  is  occluded  by  a  calculus,  repeated 
attacks  of  colic  are  apt  to  occur,  attended  with  excruciating 
pain,  referred  to  the  right  hypochondrium  ;  and  occasionally 
one  or  more  calculi  are  expelled  into  and  from  the  intestine,  so 
as  to  be  found  in  the  stools.  If  the  calculus  is  large,  or  if  more 
than  one  is  present,  they  may  be  detected  by  palpation,  and 
fremitus  and  friction-sound  may  be  appreciable.  Colic  and  se- 
vere pain  are  wanting  in  catarrhal  jaundice,  the  icterus  of  which 
is  apt  to  be  less  intense  and  less  protracted  than  that  of  ob- 
structive disease, 


260  ESSENTIALS   OF   DIAGNOSIS. 

In  compression  of  the  common  bile-duct,  the  portal  vein  is 
likely  also  to  be  compressed,  so  that  ascites  develops.  When 
such  compression  is  dependent  upon  an  enlarged  gland  this  may 
be  palpable  from  without. 

Pylephlebitis  is  likely  to  be  associated  with  cirrhosis  or  syphilis 
of  the  liver,  a  new-growth  of  the  portal  vein,  adjacent  prolifer- 
ative peritonitis,  perforation  by  gall-stones  or  by  a  suppurating 
hydatid  cyst,  and  may  be  attended  with  the  sudden  onset  of 
symptoms  of  engorgement  of  the  portal  system,  with  hemat- 
emesis,  melena,  ascites  and  splenic  enlargement.  It  may  be 
secondary  to  ulcerative  disease  of  the  bowel,  as  appendicitis  or 
dysentery ;  or  due  to  the  presence  of  a  foreign  body,  as  a  i^in. 
In  addition  to  febrile  phenomena  there  may  be  evidences  of 
pyemia  or  septicemia. 

Ifalignant  disease  may  involve  the  biliary  passages  or  the  sur- 
rounding structures.  A  malignant  growth  occasions  emaciation 
and  a  peculiar  cachexia  manifested  by  a  straw-colored  com- 
plexion. Ascites,  tumor,  repeated  rigors,  decided  fever,  ema- 
ciation and  cachexia  are  wanting  in  catarrhal  jaundice. 

Yellow  fever  is  an  epidemic,  infectious  disease,  characterized 
by  a  train  of  grave  symptoms,  including  headache,  pains,  fever, 
vomiting  and  prostration,  that  is  wanting  in  catarrhal  jaundice. 

Weil's  disease  also  is  accompanied  by  pronounced  constitu- 
tional manifestations,  including  fever,  headache,  vertigo,  ma- 
laise, albuminuria,  hemorrhages. 

When  malarial  fever  is  attended  with  jaundice,  there  are  com- 
monly, in  addition,  chills,  fever,  sweats  and  perhaps  hematuria. 

The  symptoms  of  acute  yelloio  atrophy  of  the  liver  may  super- 
vene upon  those  of  an  apparently  catarrhal  jaundice.  In  such 
a  case  the  area  of  hepatic  percussion-dulness  rapidly  becomes 
diminished,  cerebral  symptoms  appear,  the  urine  contains 
lucin  and  tyrosin,  and  is  deficient  in  urea,  uric  acid,  chlorids, 
phosphates  and  suliDhates,  and  death  is  the  usual  issue. 

When  jaundice  attends  portal  cirrhosis  of  the  liver,  the  dis- 
coloration is  gradual  in  onset  and  slight  in  degree.  There  are, 
besides,  enlargement  or  shrinkage  of  the  liver,  enlargement  of 
the  abdominal  veins,  and  ascites.  In  biliary  cirrhosis  jaundice 
may  appear  early,  be  pronounced  and  be  unattended  with 


BILIARY    CALCULI.  261 

ascites,  but  associated  with  enlargement  of  the  spleen  as  well  as 
of  the  liver. 

Biliary  Calculi. 

What  are  the  clinical  manifestations  of  biliary  calculi  ? 

Biliary  calculi  are  more  common  in  women  than  in  men,  and 
late  in  life  than  early.  Thej^  result  from  the  precipitation  and 
agglomeration  of  the  less  soluble  elements  of.  the  bile.  They 
may  be  single  or  multiple.  They  occasion  symptoms  when 
they  give  rise  to  obstruction.  Wlien  large  or  more  than  one 
is  present  they  may  be  detected  by  palpation,  and  a  peculiar 
fremitus  may  be  appreciable,  and  on  auscultation  a  character- 
istic friction-sound.  The  presence  of  biliary  calculi  may  be  de- 
tected by  means  of  fluoroscopy  or  skiagraphy. 

The  passage  of  a  gall-stone  through  the  common  bile-duct  is 
attended  with  excruciating  colicky  pain  in  the  right  hypochon- 
drium,  radiating  at  times  to  the  shoulder,  wdth  shivering,  eleva- 
tion of  temperature,  nausea,  vomiting  and  hiccough.  The  face 
is  pale  and  the  surface  of  the  body  is  covered  with  a  cold  sweat. 
Jaundice  soon  develops — transient,  if  the  calculus  passes  into 
the  bowel ;  persistent,  if  the  calculus  remains  impacted  in  the 
common  duct.     The  spleen  may  be  enlarged. 

By  ulceration  and  perforation  an  impacted  gall-stone  may 
find  its  way  into  the  stomach,  the  bowel  or  the  peritoneal 
cavity,  or  it  may  be  evacuated  externally  through  the  walls  of 
the  abdomen. 

Attacks  of  hepatic  colic  are  prone  to  be  repeated.  Occlusion 
of  the  common  or  of  the  hepatic  duct  is  followed  by  stagnation 
of  bile,  increased  secretion  of  mucus,  and  ultimately  by  the 
formation  of  pus.  The  gall-bladder  may  become  distended  into 
a  great  sac,  and  the  accumulation  advance  into  the  biliary 
radicles.  Under  such  circumstances,  jaundice  persists  and  a 
type  of  fever  develops  that  has  been  designated  hepatic  inter- 
mittent. Periodic  elevations  of  temperature  occur,  preceded 
by  rigors  and  followed  by  sw^eats.  Unless  relief  is  aflforded, 
death  ultimately  results  from  cholemia  or  from  acholia. 

Biliary  calculi  and  carcinoma  of  the  biliary  passages  are  not 
rarely  associated. 


262  ESSENTIALS    OF    DIAGNOSIS. 

How  are  hepatic  intermittent  fever  and  malarial  intermittent 
fever  to  be  differentiated  ? 

The  intermittent  fever  that  occurs  as  a  result  of  obstruction 
of  the  bihary  passages,  with  or  without  subsequent  suppuration, 
closely  resembles  malarial  intermittent  fever;  but  in  the  former, 
there  is  jaundice,  intense  and  persistent;  the  distended  gall- 
bladder or  the  obstructing  calculi  may  be  detectable  by  palpa- 
tion ;  parasites  are  not  present  in  the  blood ;  and  the  fever  does 
not  yield  to  quinin. 

How  are  hepatic  colic,  renal  colic  and  intestinal  colic  to  be 
differentiated  ? 

The  pain  of  hepatic  colic  is  referred  especially  to  the  right 
hypochondrium,  whence  it  may  radiate  to  the  right  shoulder ; 
that  of  renal  colic  is  referred  to  one  loin,  not  necessarily  the 
right,  whence  it  radiates  in  the  course  of  the  corresponding 
ureter ;  the  pain  of  intestinal  colic  is  especially  umbilical, 
whence  it  may  radiate  over  the  entire  abdomen.  Hepatic  colic 
is  soon  followed  by  jaundice  ;  the  urine  contains  biliary  pig- 
ment, and  is  greenish  or  brownish  in  color.  In  cases  of  renal 
colic,  the  urine  may  contain  pus-corpuscles,  blood-corpuscles  and 
crystalline  matters  ;  jaundice  is  wanting.  Intestinal  colic  de- 
pends upon  intestinal  derangement,  sometimes  upon  lead-poison- 
ing ;  the  urine  remains  unaltered  ;  there  is  no  jaundice. 

How  are  carcinoma  of  the  biliary  passag-es  and  obstruction 
of  the  bile-duct  by  calculi  to  be  differentiated  ? 

Obstruction  of  the  biliary  passages  either  by  gall-stones  or  by 
carcinoma  occasions  persistent  and  intense  jaundice ;  but  in 
case  of  malignant  disease  there  is  also  progressive  emaciation, 
death  usually  occurring  within  a  year  of  the  discovery  of  the 
existence  of  the  disease.  Attacks  of  hepatic  colic  attend  the 
presence  of  gall-stones  in  the  biliary  passages. 

The  obstruction  dependent  upon  calculi  may  be  overcome, 
spontaneously  or  therapeutically.  Unrelieved,  death  ultimately 
results  from  acholia  or  cholemia. 

The  diagnosis  is  often  extremely  diflflcult.  The  uncertainty 
is  increased  by  the  fact  that  calcular  obstruction  and  malignant 
disease  are  sometimes  associated.     The  detection  of  primary 


THE    SPLEEN 


263 


carcinoma  elsewhere,  or  of  metastatic  nodules,  indicates  the 
existence  of  malignant  disease.  It  was  at  one  time  thought 
that  fever  was  wanting  in  malignant  disease,  but  this  is  not  an 
invariable  rule. 


THE  SPLEEN. 

What  is  the  normal  situation  of  the  spleen,  as  determinable  by 
physical  examination  ? 
The  spleen  (Fig.  31)  is  placed  obhquely  beneath  the  ribs,  from 


Relations  of  the  spleen  (Weil).  M,  middle  line  of  back  ;  A,  B,  C,  axillary  lines; 
Sc,  line  of  scapula ;  abc  d,  limits  of  spken ;  abc'd,  limits  of  rhomboidal  spleen ; 
efg,  limits  of  kidney  ;  Ibc,  angle  between  lung  and  spleen  ;  dhg,  angle  between 
spleen  and  kidney ;  nm,  lower  margin  of  liver. 

the  ninth  to  the  twelfth,  on  the  left  side  below  the  axilla.     The 
organ  is  about  four  inches  long  by  three  inches  wide  ;  its  axis 


264  ESSENTIALS    OF    DIAGNOSIS. 

passes  downwards  and   forwards.     Posteriorly,  the  dulness  of 
the  spleen  merges  with  that  of  the  left  kidney. 

Floating  Spleen. 

To  what  symptoms  does  a  floating  spleen  give  rise? 

The  attachments  of  the  spleen  may  become  relaxed  and  pro- 
longed, so  that  the  mobility  of  the  organ  is  abnormally 
increased,  and  its  displacement  is  facilitated.  The  essential 
points  in  the  recognition  of  a  floating  spleen  are  the  presence 
of  a  solid  body  in  an  unusual  situation,  the  absence  of  the 
spleen  from  its  normal  seat,  the  possible  facility  of  replacement 
and  the  absence  of  pronounced  symptoms. 

Splenitis. 

What  are  the  symptoms  of  splenitis  ? 

Inflammation  of  the  spleen  is  a  condition  clinically  obscure. 
It  may  occur  in  the  course  of  infectious  diseases  or  may  be  set 
up  by  emboli  swept  into  the  splenic  vessels.  It  has  in  cases 
been  attributed  to  traumatism.  Under  such  circumstances  the 
organ  becomes  enlarged.  There  are  pain  and  tenderness  in  the 
left  hypochondrium,  or  rather  at  the  lower  lateral  aspect  of  the  left 
chest,  aggravated  by  respiration  ;  there  are  also  nausea,  vomit- 
ing and  elevation  of  temperature.  Inflammation  of  the  spleen 
may  terminate  in  suppuration.  Then  chills,  fever  and  sweats 
are  superadded.  The  greatest  danger  is  from  the  rupture  of  an 
abscess  into  the  peritoneal  cavity.  Symptoms  resembling  those 
of  exophthalmic  goiter  have  been  noted  in  a  case  of  splenic 
abscess. 


Enlargement  of  the  Spleen.— Splenic  Tumor. 

Under  what  conditions  does  enlargement  of  the  spleen  take 
place  ? 

Enlargement  of  the  spleen  may  occur  in  conjunction  with 
infectious  diseases,  particularly  typhoid  fever,  malarial  fever, 


CARCINOMA   OF   THE   PANCREAS.  265 

pyemia,  septicemia ;  cirrhosis  of  the  Uver ;  venous  stasis ;  amy- 
loid degeneration  ;  hemorrhagic  infarction,  and  leukemia. 

Splenomegaly  (Banti's  Disease). 

What  is  splenomegaly  ? 

This  is  a  morbid  condition  characterized  by  enlargement  of 
the  spleen,  with  anemia,  diminution  in  the  size  of  the  liver, 
jaundice  and  ascites.  The  etiology  is  undetermined.  The  dis- 
ease occurs  most  commonly  in  young  persons  and  adolescents. 
Its  duration  may  cover  years,  and  death  finally  results. 

THE  PANCREAS. 

Acute  Pancreatitis. 

What  are  the  symptoms  of  acute  pancreatitis? 

The  frequency  of  acute  pancreatitis  is  not  known,  as  the  con- 
dition is  difficult  of  recognition.  It  may  result  from  extension 
of  adjacent  inflammation,  from  the  irritation  of  matters  con- 
tained in  the  blood,  from  traumatism  and  from  hemorrhage 
into  the  pancreas.  It  is  characterized  by  acute,  deeply-seated 
pain  and  tenderness  in  the  epigastric  region,  or  perhaps  colicky 
pain,  shooting  to  the  back  and  shoulders ;  by  anorexia,  thirst, 
nausea,  vomiting  of  a  thin  viscid  liquid,  sometimes  of  bile  ; 
by  tympanites,  dyspnea,  restlessness,  anxiety  and  depression ; 
by  febrile  symptoms  ;  and  usually  by  constipation— phenomena 
similar  to  those  presented  by  peritonitis.  In  some  cases  there 
is  diarrhea,  the  stools  being  thin,  watery,  and  resembling  saliva. 
Suppuration  may  take  place  in  the  pancreas  and  an  abscess 
form.  Gangrene  of  the  organ  may  be  a  sequel.  Death  is  the 
usual  termination.  It  may  be  sudden,  with  the  phenomena  of 
collapse.  Fat-necrosis  is  a  common  accompaniment  of  all 
forms  of  pancreatic  disease. 

Carcinoma  of  the  Pancreas. 

What  are  the  symptoms  of  carcinoma  of  the  pancreas  ? 

New-groidhs  of  the  pancreas  are  not  common,  but  of  those  that 


266  ESSENTIALS    OF    DIAGNOSIS. 

occur  carcinoma  is  the  commonest.  The  disease  may  be 
primary  or  secondary.  The  head  of  the  organ  is  involved  in 
most  instances.  Symptoms  may  long  be  latent.  Among  the 
most  constant  are  epigastric  pain,  jaundice  and  distention  of 
the  gall-bladder  from  pressure  on  the  biliary  passages,  the 
presence  of  a  tumor,  wasting  and  cachexia.  Pressure  on  the 
pylorus  may  give  rise  to  dilatation  of  the  stomach,  with  nausea 
and  vomiting.     There  may  be  fatty  diarrhea. 


Pancreatic  Cysts, 

What  are  the  clinical  features  of  cysts  of  the  pancreas  ? 

Cysts  of  the  pancreas  may  arise  from  retention  and  accumu- 
lation of  fluid  in  an  occluded  or  obstructed  pancreatic  duct, 
from  the  proliferation  of  pancreatic  tissue,  or  as  a  result  of 
traumatism  or  inflammatory  processes,  leading  to  hemorrhage 
and  dropsy  of  the  lesser  peritoneal  cavity.  Among  the  most 
common  symptoms  are  colicky  pains  in  the  abdomen,  with 
nausea  and  vomiting  and  the  appearance  of  a  comparatively 
fixed  tumor  in  the  upper  half  of  the  abdomen.  The  bowels 
may  be  loose  and  the  stools  contain  undigested  fat.  Jaundice 
and  ascites  may  result  from  pressure.  The  urine  may  contain 
albumin  or  sugar,  and  the  secretion  of  saliva  may  be  increased. 
Loss  of  weight  and  failure  in  strength  usually  take  place.  Fluid 
obtained  on  puncture  may  contain  blood-corpuscles  or  hemo- 
globin, granular  detritus,  fjxt  globules  and  cholesterin,  and  it 
may  exhibit  the  fermentative  activity  of  pancreatic  juice. 


Pancreatic  Hemorrhage. 

What  are  the  symptoms  of  hemorrhage  into  the  pancreas  ? 

Hemorrhage  into  the  pancreas  is  characterized  by  the  occur- 
rence of  severe  pain  of  sudden  onset  in  the  upper  part  of  the 
abdomen,  with  nausea,  vomiting,  a  sense  of  anxietj^  restless- 
ness, depression,  coldness  of  the  surfiice,  sweating,  a  weak, 
rapid  pulse,  tympanites,  constipation. 


THE    GENITO-URINARY    APPARATUS.  267 

THE  GENITO-URINARY  APPARATUS. 

Examination  of  the  urine  is  important  not  only  when  disease  in 
the  genito-urinary  tract  is  suspected,  but  also  in  many  other 
varied  conditions. 

The  constitution  of  the  urine  may  be  quantitatively  or  qualita- 
tively altered.  The  proportions  of  normal  ingredients  may  be 
increased  or  diminished.  Substances  not  normally  found  in 
the  urine  may  under  certain  conditions  be  present. 

The  quantity  of  urine  excreted  by  a  healthy  adult  in  twenty- 
four  hours  varies  between  forty  and  fifty  ounces.  The  quantity 
is  physiologically  increased  after  the  ingestion  of  large  quantities 
of  fluid  and  when  the  cutaneous,  pulmonar}^  and  intestinal 
transpiration  is  diminished.  The  quantity  is  ^physiologically 
diminished  under  the  reverse  conditions. 

The  quantity  of  urine  excreted  is  altered  in  many  conditions 
of  disease.  It  is  increased  in  diabetes  insipidus  and  diabetes 
mellitus,  in  chronic  nephritis  and,  temporarily,  in  emotional 
states,  including  hysteria.  The  quantity  of  urine  is  diminished 
in  acute  nephritis,  in  the  last  stages  of  chronic  nephritis,  in 
lithemia,  in  renal  insufficiency,  in  conditions  characterized  by 
feebleness  of  the  heart,  in  Asiatic  cholera,  in  yellow  fever,  in 
acute  intestinal  obstruction  and  in  febrile  conditions  generally. 

Urine  is  normally  clear,  transparent,  of  an  amber  color,  with- 
out obtrusive  odor,  of  acid  reaction  and  a  specific  gravity  varying 
from  1010  to  1030.  The  color  is  paler  or  darker,  and  the  specific 
gravity  lower  or  higher,  as  the  quantity  is  increased  or  dimin- 
ished. 

The  transparency  of  the  urine  is  interfered  with  by  the  presence 
of  matters  rendered  insoluble  by  an  altered  reaction  of  the 
urine  (such  as  phosphates),  or  by  a  change  of  temperature  (such 
as  urates)  ;  by  the  presence  of  matters  foreign  to  normal  urine 
(such  as  pus,  chyle  or  bloodj  ;  and  sometimes  as  a  result  of  the 
action  of  bacteria. 

The  color  of  urine  is  intensified  when  the  quantity  is  dimin- 
ished, as  in  fevers,  or  when  the  action  of  the  skin  is  increased. 
The  color  is  altered  by  the  ingestion  of  some  medicaments  and 
foods  and  by  the  presence  of  other  abnormal  ingredients.    Thus, 


268  ESSENTIALS    OF    DIAGNOSIS. 

rhubarb  imparts  a  gamboge-yellow  color  to  acid  urine,  a  violet-red 
to  alkaline  urine  ;  santonin  imparts  a  golden-yellow  to  acid  urine, 
an  orange-yellow  to  alkaline  urine  ;  senna  imparts  a  brownish, 
logwood  a  reddish,  carbolic  and  gallic  acids  each  a  blackish 
tinge.  Urates  may  color  the  urine  orange-red.  The  presence 
of  blood  gives  rise  to  a  smoky,  reddish  or  chocolate  color  ;  the 
presence  of  biliary  pigment  to  a  brownish  or  greenish  hue  ;  the 
presence  of  chyle  to  a  milky  appearance.  In  cases  of  melanotic 
tumors  the  urine  may  be  dark  or  black  ;  the  color  is  likewise 
dark  in  some  cases  of  pernicious  anemia.  The  urine  is  pale 
when  it  is  excreted  in  excess,  as  in  hysteria,  in  diabetes  and  in 
chronic  nephritis. 

The  odor  of  normal  urine  is  typical,  but  not  obtrusive.  When 
fermentation  takes  place  the  urine  becomes  amnion iacal.  The 
ingestion  of  turpentine  imparts  to  the  urine  an  odor  of  violets. 
Other  aromatic  oils  impart  odors  abnormal  to  urine.  The  urine 
of  diabetes  mellitus  has  a  sweetish  odor.  If  it  contain  acetone, 
the  odor  resembles  that  of  chloroform. 

The  total  twenty-four  hours'  urine  of  a  healthy  person  is  of 
acid  reaction.  The  urine  may  be  alkaline  from  fixed  alkali  a 
few  hours  after  a  meal,  especially  if  large  quantities  of  alkalies 
have  been  taken  ;  in  cases  in  which  the  stomach  is  washed  out ; 
and  in  cases  of  obstinate  vomiting.  The  urine  is  alkaline  from 
volatile  alkali  when  ammoniacal  fermentation  has  taken  place. 

The  average  specific  gravity  of  normal  urine  is  1018  or  1020. 
Except  in  diabetes  mellitus,  the  specific  gravity  bears  in  gen- 
eral an  inverse  relation  to  the  quantity  of  urine.  It  is  height- 
ened after  the  ingestion  of  large  quantities  of  nitrogenous  food, 
in  diabetes  mellitus  and  in  acute  nephritis  and  other  febrile 
conditions.  It  is  lowered  in  diabetes  insipidus,  in  chronic 
nephritis,  in  hysteria,  when  the  activity  of  the  skin  is  lowered 
and  after  the  ingestion  of  large  quantities  of  fluid. 

The  normal  average  quantity  of  urea  excreted  in  twenty-four 
hours  is  about  five  hundred  grains.  The  excretion  of  urea  is 
increased  on  a  generous  nitrogenous  diet  and  in  fevers  in 
which  the  urine  is  not  suppressed.  The  quantity  of  urea  in 
the  urine  is  diminished  on  a  vegetable  diet ;  when  oxidation 
is  interfered  with,  as  in  pulmonary  or  cardiac  disease  ;  in  cases  of 


THE    GENITO-URINAllY    APPARATUS. 


269 


grave  hepatic  disease,  renal  insufficiency  or  suppression  of  urine ; 
and  when  the  urea  is  retained  in  the  circulation. 

If  urine  or  any  tiuid  containing  urea  be  concentrated  to  a 
syrupy  consistence,  by  evaporation  in  a  water-bath,  and  nitric 


Fig.  32. 


Uric  acid  and  urates.    (Funke.) 

acid  be  added,  a  crystalline  precipitate  of  the  rhombic  plates  of 
urea  nitrate  will  be  thrown  down. 

The  quantity  of  uric  add  excreted  in  the  urine  in  twenty -four 
hours  varies  from  eight  to  sixteen  grains.  It  is  increased  when 
the  diet  is  nitrogenous  ;  when  oxidation  is  defective,  as  in  pul- 
monary or  cardiac  disease;  after  an  attack  of  gout  or  lithemia; 
and  in  febrile  processes.  It  is  diminished  on  a  diet  of  carbo- 
hydrates ;  in  chronic  diseases  after  hemorrhage ;  during  an  at- 
tack of  gout  or  lithemia. 

If  ten  parts  of  hydrochloric  acid  be  added  to  one  hundred 
parts  of  urine  and  the  mixture  be  permitted  to  stand  for  forty- 
eight  hours,  a  sediment  of  fine,  red  crystals  of  uric  acid  will  form. 

The  quantity  of  hipimric  add  excreted  in  the  urine  in  tw^enty- 
four  hours  is  between  eight  and  thirty  grains.  It  is  increased  on 
a  vegetable,  and  dimini.-<hed  on  an  animal  diet.  It  is  only  pre- 
cipitated from  acid  urine,  when  it  appears  as  rhombic  crystals. 

The  quantity  of  sodium  chloride  excreted  in  the  urine  in 


270 


ESSENTIALS    OF   DIAGNOSIS. 


twenty-four  hours  is  about  half  an  ounce.  It  depends  upon 
the  quantity  ingested.  The  excretion  of  chlorides  is  dimin- 
ished in  febrile  disorders,  and  especially  when  exudation  or 
transudation  occurs. 

Tlie  presence  of  chlorides  in  the  urine  may  be  determined  by 
first  acidulating  Uie  urine  with  nitric  acid,  and  then  adding  a 
solution  of  silver  nitrate.     If  the  precipitate  that  forms  is  dense 


Calcium  phosphate.     (Laache.) 

and  curdy,  the  quantity  of  chlorides  is  normal ;  if  the  precipitate 
is  milky,  the  chlorides  are  diminished. 

Between  thirty  and  eighty  grains  of  phosphoric  acid  are 
eUminated  in  the  urine  in  twenty-four  hours,  two-thirds  as 
alkaline  (acid  sodium  and  potassium)  phosphates,  and  one- 
third  as  earthy  (calcium  and  magnesium)  phosphates.  The 
quantity  of  phosphates  excreted  is  diminished  at  the  beginning 
of  febrile  processes,  and  increases  with  defervescence  and  con- 
valescence. 

The  earthy  phosphates  are  precipitated  when  the  reaction  of 
the  urine  is  alkaline.  The  alkaline  phosphates  are  precipitated 
by  the  addition  of  a  solution  containing  one  part  each  of  mag- 
nesium sulphate,  ammonium  chloride  and  liquor  ammonise,  and 
eight  parts  of  distilled  water. 


THE    (JENITO-URINAIIY    APPARATUS. 


271 


About  thirty  grains  of  sulphuric  acid  are  eliminated  as  sul- 
phates in  the  urine  in  twenty-four  hours.  The  quantity  varies 
with  the  character  of  the  food  and  the  degree  of  activity. 

The  presence  of  sulphates  in  the  urine  is  determined  by  the 
addition  of  a  solution  of  barium  chloride,  -w  hich  gives  a  cloudy 
precipitate,  insoluble  iu  water  or  acids. 

Biliarij  coloring  matter  appears  in  the  urine  when  jaundice 
exists.      The  urine   is  yellowish,  greenish   or   olive-brown   in 


Fig.  34. 


Triple  phosphates  and  ammonium  urate.     (Laache.) 

color,  and  stains  the  linen.  TThen  the  jaundice  is  not  due  to 
biliary  obstruction  it  is  said  that  the  biliar}^  acids  are  not  found 
in  the  urine. 

The  presence  of  biliary  coloring  matter  in  the  urine  may  be 
detected  by  overlaying  nitric  acid  in  a  test-tube  witb  urine, 
or  by  permitting  the  fusion  of  a  drop  each  of  nitric  acid  and  of 
urine  on  a  white  plate.  A  play  of  color  from  green,  blue, 
violet,  red  to  yellow,  results. 

To  detect  the  presence  of  the  biliary  acids  in  the  urine  a  small 
quantity  of  cane-sugar  is  added  to  the  urine,  which  is  introduced 
into  a  test-tube,  so  as  to  overlay  some  sulphuric  acid.  A  purple 
Qoloy  is  formed  at  the  line  of  contact.     If  a  bit  of  tilter-paper  is 


272 


ESSENTIALS    OF    DIAGNOSIS. 


dipped  in  the  saccharated  urine  and  touched  with  a  drop  of 
sulphuric  acid  a  purple  color  results. 
What  are  leucin  and  tyrosin  ? 

Leucin  and  tyrosin  are  products   of  the   destructive   meta- 
morphosis of  proteids,  and  are  among  the  waste-products  of 

Fig.  35. 


Leucin  and  tyrosin.     (Laache.) 


pancreatic  digestion.  They  do  not  occur  in  normal  urine,  but 
are  found  in  the  urine  in  cases  of  phosphorus-poisoning  and  of 
acute  yellow  atrophy  of  the  liver,  for  which  they  may  have 
diagnostic  significance.  They  have  also  been  exceptionally 
noted  in  variola,  typhus,  pernicious  anemia,  and  in  a  case  of 
obstructive  jaundice  caused  by  hydatid  cyst  of  the  gall-duct. 

To  obtain  leucin  and  tyrosin  in  the  sediment,  the  urine  should 
be  evaporated  in  a  water-bath  to  syrupy  consistence,  or  a  drop 
may  be  boiled  down  on  an  object-glass.  Leucin  appears  in  the 
form  of  faintly  shining  spheres  of  variable  size,  the  larger  ones 
sometimes  exhibiting  radiation  or  concentric  rings.  Tyrosin 
crystallizes  in  very  fine  needles,  commonly  aggregated  into 
sheaves  or  bundles. 


I  N  D  I  C  A  N  U  R  I A  —  O  X  A  L  U  II I  A 


273 


Indicanuria. 

What  is  indicanuria  ? 

Tlie  presence  in  the  urine  of  potassium  indoxj'l-sulphate  is 
known  as  indicanuria.  Indican  results  from  the  decomposi- 
tion hy  hacteria  of  alhumin  in  the  intestines,  and  it  occurs  in 
normal  urine  in  only  small  amounts.  The  quantity  is  increased 
in  wasting  diseases  and  when  excessive  albuminous  disintegra- 
tion is  taking  place.  Its  presence  is  disclosed  by  the  bluish- 
black  discoloration  that  takes  place  when  2  or  3  drops  of  solu- 
tion of  chlorinated  soda  are  added  to  equal  parts  of  urine  and 
strong  hydrochloric  acid.  On  shaking  with  chloroform,  indigo 
is  dissolved  out  and  settles  at  the  bottom. 


Oxaluria. 

What  is  oxaluria  ? 

The  presence  of  oxalates  in  the  urine  is  sometimes  associated 
with  a  complex  of  s3'mptoms,  to  which  the  designation  oxaluria 
has  been  applied.  Individuals  so  affected  complain  of  languor, 
of  dull  pains  in  the  loins,  are  irritable  or  dejected,  have  boils  or 

Fig.  36. 


Calcium  oxalate.     (Laache.) 

carbuncles  ;   and  their  nutrition  is  impaired.     The  inline,  the 
18 


274  ESSENTIALS    OF    DIAGNOSIS. 

specific  gravity  of  which  is  increased,  contains  an  excess  of  urea 
and  of  oxahites,  and  occasionally  a  trace  of  albumin.  The  con- 
dition has  been  observed  in  persons  in  whom  the  nervous  system 
has  been  severely  put  to  task.  The  oxalates  in  the  urine  may 
be  increased  by  certain  foods,  such  as  tomatoes  and  rhubarb. 
By  accretion  they  ma^^  form  calculi. 

Pyuria. 

What  is  pyuria  ? 

The  presence  of  pus  in  the  urine  constitutes  pyuria.  Pus 
appears  in  the  urine  when  there  is  suppuration  iu  any  portion 
of  the  genito-urinar}'  tract,  as  in  urethritis,  cystitis,  ureteritis  or 
pyelitis.  Kupture  of  an  abscess  into  the  genito-urinary  pas- 
sages gives  rise  to  the  sudden  discharge  of  a  large  quantity  of 
pus.  When,  in  women,  leucorrhea  exists,  some  of  the  pus  may 
find  its  way  into  the  receptacle  for  urine.  The  addition  of 
caustic  alkalies  converts  pus  into  a  gelatinous  viscid  mass.  Hy- 
drogen dioxide  gives  a  characteristic  foaminess,  from  libera- 
tion of  oxygen.  The  microscope  is  the  most  certain  test. 
Urine  containing  pus  responds  to  chemic  tests  for  albumin. 

When  urethritis  exists,  micturition  is  burning.  The  first 
urine  passed  is  turbid  ;  that  which  follows  may  be  clear.  The 
reaction  of  the  urine  remains  unchanged.  In  the  vast  majority 
of  cases,  urethritis  is  gonorrheal. 

When  there  is  cystitis,  there  may  be  vesical  tenesmus,  with 
frequent  passage  of  small  quantities  of  urine  that  is  usually 
of  alkaline  reaction.  Cystitis  may  be  secondary  to  urethritis  ; 
it  may  be  a  result  of  obstruction,  as  from  stricture  of  the  urethra 
or  an  enlarged  prostate;  it  may  be  associated  with  a  calculus 
in  the  bladder  ;  it  may  have  been  caused  by  the  introduction  of 
septic  matters  into  the  bladder  in  the  course  of  some  surgical 
procedure,  such  as  the  employment  of  an  unclean  catheter, 
sound  or  bougie  ;  it  may  be  tuberculous  ;  it  is  often  seen  in  asso- 
ciation with  diseases  of  the  brain  and  spinal  cord.  The  urine  is 
not  only  turbid,  but  it  is  usually  also  alkaline  in  reaction  and 
offensive  in  odor,  from  ammoniacal  fermentation. 

Ureteritis  and  pyelitis  are  usually  associated.     Both  are  com- 


ALBUMINURIA.  275 

monly  secondary  to  cystitis,  thoiiorh  they  may  result  from  the 
presence  of  calculi.  In  uncomplicated  cases  the  urine  is  acid 
in  reaction. 

When  an  abscess  ruptures  into  the  genito-urinary  tract,  a 
certain  sense  of  relief  of  tension  is  perceived,  followed  by  the 
evacuation  of  a  large  quantity  of  pus  in  the  urine,  which  had 
previously  presented  no  abnormal  characters. 

Albuminuria. 

What  is  albuminuria  ? 

Albumin  is  found  in  the  urine  under  many  varied  conditions  ; 
thus,  urine  containing  pus  or  blood  will  respond  to  the  tests  for 
albumin.  Under  other  circumstances,  however,  the  albumin  is 
derived  directly  from  the  circulating  blood,  as  a  result  of  defec- 
tive action  of  the  epithelium  of  the  secretory  apparatus  of  the 
kidney,  or  of  changes  in  the  blood  or  in  vascular  tension.  Such 
a  condition  is  present  in  the  A^arious  morbid  states  of  the  kid- 
ney, in  the  course  of  fevers  and  toxic  and  infectious  processes 
and  in  association  with  violent  convulsions,  obstructive  disease 
of  the  heart,  and  interference  with  the  respiratory  function. 
The  ordinary  form  of  albumin  found  in  the  urine  is  serum- 
albumin  ;  less  commonly  paraglobulin  is  present. 

How  is  the  presence  of  albumin  in  the  urine  to  be  determined  ? 

The  best  test  for  the  detection  of  albumin  in  the  urine  is  that 
by  heat.  The  urine  should  be  clear  and  of  acid  reaction.  If 
not  clear,  it  should  be  filtered.  If  not  acid,  a  drop  or  two  of 
acetic  acid— sufficient  to  impart  an  acid  reaction,  should  be 
added.  The  upper  half  of  the  urine,  in  a  test-tube,  is  heated. 
A  resulting  cloudiness  is  due  to  the  presence  of  albumin  or  of 
phosphates.  If  the  urine  have  been  acid,  the  cloudiness  is  not 
likely  to  be  due  to  phosphates.  The  addition  of  a  few  drops  of 
acetic  acid  removes  any  doubt ;  if  the  cloudiness  is  dependent 
upon  the  presence  of  phosphates,  it  at  once  clears  ;  if  due  to 
the  presence  of  albumin,  it  persists.  To  the  filtered  urine  about 
one-sixth  its  quantity  of  saturated  solution  of  sodium  chlorid 
and  5  or  10  drops  of  dilute  acetic  acid  {50  fc)  may  be  added  be- 
fore heat  is  applied. 


276 


ESSENTIALS     OF    DIAGNOSIS, 


A  simpler  test  for  the  presence  of  albumin  consists  in  overlay- 
ing a  quantity  of  cold  nitric  acid  in  a  test-tube  with  the  urine. 
A  white  ring  at  the  line  of  contact  of  the  two  fluids  is  indicative 
of  the  presence  of  albumin.     Its  appearance  may  be  delayed. 


Fig.  38. 


Red  blood-corpuscles  and  a  blood-cast 
of  a  uriniferous  tubule.    (Eichhorst.) 


Fig.  39. 


W  m 


Eiiitbellal  cast  of  a 
uriniferous  tubule. 
(V.  Jaksch.) 

Fig.  40. 


Granular  casts  of  the  uriniferous 
tubules.     (V.  Jaksch.) 


Hyaline  casts  of  the  uriniferous 
tubules.    (Vierordt.) 


A  faint  ring  of  urates  that  forms  above  the  line  of  contact  is 
dissipated  by  the  application  of  heat.  A  mixture  of  one  part  of 
strong  nitric  acid  and  five  of  saturated  solution  of  magnesium 
sulphate  may  be  emploj^ed  in  the  same  way. 


ALBUMINURIA 


277 


Another  test  consists  in  adding  to  half  a  test-tubeful  of  urine 
a  dram  or  more  of  solution  of  potassium  ferrocyanid  (1  :20); 
and  after  thorough  admixture,  about  10  drops  of  dilute  acetic 
acid  (50%).  The  occurrence  of  turbidity  indicates  the  pres- 
ence of  albumin. 

A  saturated  solution  of  picric  acid  used  by  the  contact-method 
in  the  same  way  as  nitric  acid,  the  urine,  however,  being  over- 

FiG.  41. 


I'm 


Waxy  easts  of  the  uriniferous  tubules,    a,  a  waxy  cast  containing  crystals  of 
calcium  oxalate.    (Y.  Jaksch.) 

laid  by  the  acid,  constitutes  a  most  delicate  test  for  the  detec- 
tion of  albumin  in  the  urine,  but  it  is  equivocal,  as  it  reacts  with 
peptones,  urates  and  with  the  alkaloids.  Heat,  it  is  true,  dissi- 
pates the  ring  formed  with  these,  but  it  mav  also  cause  a  diffu- 


278  ESSENTIALS    OF    DIAGNOSIS. 

sion  of  the  turbidity  produced  by  albumin,  so  that  the  latter 
may  escape  detection. 

What  is  the  significance  of  the  presence  of  tube-casts  in  the 
urine  ? 

The  presence  in  the  urine  of  casts  of  the  uriniferous  tubules  is 
indicative  of  nephritis.  The  presence  of  albumin  is  usually 
associated  with  that  of  tube-casts.  Albumin  and  tube-casts 
may,  however,  be  absent,  or  at  least  escape  detection,  at  times 
when  nephritis  exists ;  and  they  may  occasionally  be  present 
unassociated  with  inflammation  of  the  kidney.  Centrifugation 
should  be  practised  when  tube-casts  are  not  otherwise  readily 
found. 

The  character  of  the  casts  varies  according  to  the  form  of 
nephritis.  Blood-casts  and  epithelial  casts  are  indicative  of  an 
acute  process  ;  granular  casts  of  a  chronic  process  ;  hyaline  casts 
may  be  present  in  many  conditions.  Fatty  casts  bespeak  the 
late  stage  of  a  chronic  parenchymatous  nephritis — fatty  kidney  ; 
wnxy  casts  may  be  found  in  acute  and  chronic  nephritis  and  in 
amyloid  disease  of  the  kidney. 

Chyluria. 

What  is  chyluria  ? 

The  presence  in  the  urine  of  chyle  or  its  molecular  base,  fat, 
constitutes  chyluria.  The  urine  presents  a  whitish,  milk}'  ap- 
pearance and  displays  a  tendency  to  spontaneous  coagulation. 

Fig.  42. 


Filaria  sanguinis  hominis.    (V.  Jaksch.) 

Albumin  is  present;  in  cases  due  to  filaria,  blood  may  be  found. 
Under  the  microscoiDe  lymph-corpuscles  and  a  finely  granular 


LIPURtA HEMATURIA.  279 

basis  are  recognized.  Chyle  finds  its  way  into  the  urine  as  a 
result  of  abnormal  communication  between  the  lymphatic  sys- 
tem and  the  genito-urinary  tract,  in  consequence  of  rupture 
following  obstruction  in  the  lymph-channels,  most  commonly 
hyftlaria  saiiguinis  homims.  The  scrotum  and  the  lower  ex- 
tremities are  sometimes  infiltrated,  and  may  be  enlarged  so  as 
to  create  a  resemblance  to  elephantiasis.  Filariasis  is  a  chronic 
affection,  as  a  rule  irregularly  intermittent  in  its  manifestations. 
When  filarire  are  present,  ova  or  embryos  should  be  discovered 
in  the  lymph  or  in  the  blood. 

Filaria  nocturna  appears  during  the  period  of  sleep  or  rest, 
therefore  usually  at  night ;  filaria  diurna,  during  the  period  of 
activity,  therefore  usually  by  day ;  while  filaria  pustano  may  be 
found  at  any  time. 

Lipuria. 

What  is  lipuria  ? 

The  presence  of  fat  in  the  urine  constitutes  lipuria.  It  may 
occur  in  health  after  excessive  ingestion  of  fatty  food.  It  has 
been  observed  in  connection  with  fatty  degeneration  of  the 
kidney,  pyonephrosis,  diabetes  raellitus,  phosphorus-poisoning 
and  pregnancy.  Urine  containing  chyle  responds  to  the  tests 
for  fat.  The  condition  may  be  recognized  by  the  addition  to 
the  urine  of  a  small  quantity  of  potassium  hydrate  and  then 
shaking  with  ether.  The  ether  is  permitted  to  evaporate  and 
the  fat  collects  as  globules. 

Hematuria. 

What  is  hematuria  ? 

The  presence  of  blood  in  the  urine  constitutes  hematuria. 
The  urine  is  turbid  and  darker  in  color  than  normal ;  the  specific 
gravity  is  increased  ;  and  albumin  is  present  in  considerable 
quantity.  AVith  the  microscope  there  is  no  difficulty  in  distin- 
guishing the  red  corpuscles. 

Blood  may  be  present  in  the  urine  as  a  result  of  hemorrhage 
from  traumatism,  stone,  neoplasm,  tuberculosis,  inflammation 
or  ulceration  in  the  genito-urinary  tract ;  as  a  symptom  of  cer- 
tain nervous  diseases ;  as  a  manifestation  of  a  hemorrhagic  dia- 


280  ESSE  N'T  lALS    OF   DIAGNOSIS. 

thesis,  as  in  leukemia,  scurvy,  purpura,  hemophilia,  exophthal- 
mic goiter,  and  the  like  ;  as  a  manifestation  of  influenza  or  ma- 
laria, or  as  the  result  of  drug-action.  Like  chyluria,  hematuria 
may  be  due  to  Filaria  sanguinis  hominis.  Distoma  hematohium 
and  strongylus  gigas  are  additional  parasites  that  may  cause 
hematuria. 

It  may  sometimes  be  important  to  determine  whether  the  blood 
present  in  urine  comes  from  the  bladder  or  from  the  kidneys.  A 
comparatively  small  quantity  of  blood  ;  its  uniform  admixture 
with  the  urine  ;  the  presence  of  blood-casts  of  the  tubules,  or 
of  the  ureter;  small  size,  discoloration,  or  so-called  "ringing" 
of  the  blood-cells,  point  to  renal  hemorrhage.  The  passage  of 
pure  blood  or  of  clots  unmixed  with  urine,  or  with  but  slight 
admixture,  or  only  at  the  beginning  or  close  of  urination,  points 
to  hemorrhage  from  the  bladder  or  urethra.  Exploration  or  cys- 
toscopic  examination  may  detect  the  source  of  hemorrhage  and 
perhaps  its  cause,  as  a  calculus  or  a  neoplasm. 

Hemoglobinuria. 

What  is  hemoglobinuria  ? 

When  the  coloring-matter  of  the  blood  appears  in  the  urine 
the  condition  is  designated  hemoglohinuria.  The  coloring-matter 
of  the  blood  may  appear  free  in  the  urine  as  a  result  of  con- 
ditions attended  with  disorganization  of  the  blood,  such  as 
scurvy,  purpura,  pyemia,  typhus,  insolation,  extensive  burns, 
and  poisoning  by  potassium  chlorate,  hydrogen  arsenide,  phos- 
phorus, carbolic  acid  and  chloral.  Spontaneous  hemoglobin- 
uria has  been  observed  in  the  new-born  infant. 

The  iirine  is  dark-red  or  chocolate-brown  in  color,  of  high  spe- 
cific gravity,  and  contains  considerable  albumin.  Microscopic- 
ally, few  or  no  blood-cells  are  found.  A  drop  of  such  urine 
treated  on  a  slide  with  sodium  chloride,  acetic  acid,  and 
heat  yields  microscopically  the  flat,  rhombic,  prismatic  tables 
known  as  Teichmann's  crystals.  The  addition  of  a  few  drops 
of  fresh  tincture  of  guaiac  to  a  small  quantity  of  the  same  urine 
gives  rise  to  a  whitish  or  greenish  coloration  ;  shaken  well,  the 
addition  of  a  few  drops  of  a  solution  of  hydrogen  dioxide  or  of 


PAROXYSMAL    HEMOGLOBINURIA.  281 

old  oil  of  turpentine  causes  a  change  of  color  to  blue.    Spectro- 
scopic examination  reveals  characteristic  striae. 


Paroxysmal  Hemoglobinuria. 

What  is  paroxysmal  hemoglobinuria  ? 

Hemoglohinuria  may  be  intevmUtent  and  paroxysmal.  In  some 
cases  no  cause  for  the  condition  can  be  elicited  ;  in  most,  how- 
ever, the  exciting  factor  has  been  exposure  to  unusual  cold. 
Attacks  may  be  induced  by  mental  or  physical  exhaustion.  The 
disease  is  most  common  in  young  adult  males.  The  onset  of  a 
paroxysm  is  indicated  by  a  sense  of  languor  and  fatigue,  to 
which  is  soon  added  a  feelinsj  of  chilliness.  The  fingers  and 
toes  and  tips  of  the  ears  become  numb,  cold  and  cyanotic.  The 
paroxysm  ends  by  the  restoration  of  a  comfortable  sense  of 
warmth.  During  the  attack,  or  a  short  time  subsequently,  the 
symptom  that  gives  the  disease  its  name  appears.  The  urine, 
however,  soon  assumes  a  normal  condition.  Paroxysmal  hemo- 
globinuria may  be  part  of  the  syndrome  of  Raynaud's  disease, 
and  in  a  mild  form  may  be  associated  with  other  varieties  of 
vasomotor  ataxia. 

How  are  paroxysmal  hemoglobinuria  and  malarial  hematuria 
to  be  differentiated  1 

Paroxysmal  hemoglobinuria  is  not  known  to  be  related  to 
malarial  infection  ;  other  possible  manifestations  of  malaria  are 
wanting  ;  the  periodicity  of  the  attack  is  not  rhythmical ;  ma- 
larial hematuria  is  a  manifestation  of  profound  malarial  intoxi- 
cation, associated  with  other  distinct  characteristics  of  malaria. 
In  hematuria,  with  the  microscope,  many  red  blood-corpuscles 
are  to  be  seen  in  the  urine  ;  the  absence  of  blood-corjDuscles  in 
the  urine  is  characteristic  of  hemoglobinuria.  The  one  condi- 
tion yields  to  treatment  with  quinine  ;  the  other  does  not.  Ex- 
amination of  the  blood  in  a  case  of  paroxysmal  hemoglobinuria 
discloses  nothing  characteristic  ;  an  examination  of  the  blood  in 
cases  of  malarial  hematuria  reveals  the  jpresence  of  characteristic 
parasites. 


282  ESSENTIALS    OF    DIAGNOSIS, 


Endemic  Hematuria. 

What  is  endemic  hematuria? 

In  tropical  climates  the  presence  of  a  nematode  worm,  the 
distoma  hscmatohium  or  Bilharzia  hxmatohia,  in  the  veins  about 
the  bladder,  occasions  the  appearance  of  blood  in  the  urine. 
The  ova  of  the  parasite  find  their  way  into  the  genito-urinary 
passages  and  there  give  rise  to  irritation  and  inflammation  and 
extravasation  of  blood.  The  disease  is  most  common  in  youth  ; 
it  shows  a  tendency  to  subside  after  the  age  of  puberty.  The 
condition  predisposes  to  the  development  of  urinary  calculi. 
The  diagnosis  depends  upon  the  endemic  character  of  the  affec- 
tion and  the  detection  of  ova,  which  are  often  concealed  in 
shreds  of  tissue  contained  in  the  urine. 

Diabetes  Insipidus. 

What  are  the  clinical  features  of  diabetes  insipidus  or  poly- 
uria ? 

Diabetes  insijndus  or  polyuria  is  a  morbid  condition  character- 
ized by  the  elimination  of  an  excessive  quantity  of  feebly  acid 
urine,  of  low  specific  gravity,  containing  neither  albumin  nor 
sugar.  The  disease  is  most  common  in  young  persons,  and 
males  sufier  oftener  than  females.  The  progress  is  usually 
gradual,  at  times  rapid.  There  is  increased  thirst;  an  ab- 
normal quantity  of  fluids  may  be  ingested,  of  which,  how- 
ever, the  quantity  of  urine  excreted  is  usually  in  excess.  The 
skin  and  visible  mucous  membranes  may  be  rough  and  dry.  In 
some  cases  the  appetite  is  excessive.  The  general  nutrition  may 
be  maintained,  but  is  rather  more  likely  to  suffer  deterioration, 
as  manifested  by  wasting  and  debility.  Diabetes  insipidus  is 
not  directly  fatal.  Its  etiology  and  pathology  are  obscure.  In 
many  cases,  there  is  a  history  of  injury  to  the  head,  or  disease 
of  the  brain  is  found  post  mortem.  It  may  depend  upon  dis- 
ease of  the  pancreas.  Several  cases  have  been  found  in  a  single 
family;  in  other  instances,  some  members  of  a  family  present 
diabetes  insipidus,  others  diabetes  mellitus. 


GLYCOSURIA  —  DIABETES  MEL  LIT US.      283 

How  are  diabetes  insipidus  and  chronic  interstitial  nephritis 
to  be  differentiated  ? 

In  cases  of  chronic  interstitial  nephritis  the  quantity  of  urine 
eliminated  may  be  abnormally  large,  but  it  does  not  attain  the 
proportions  encountered  in  diabetes  insipidus ;  in  addition, 
careful  investigation  will  detect  the  presence  of  albumin  and 
casts  in  the  urine,  as  well  as  the  existence  of  other  symj^toms 
indicating  a  degenerative  lesion  of  the  kidney  :  heightened  arte- 
rial tension,  hypertrophy  of  the  heart,  breathlessness,  edema, 
headache,  diarrhea. 

How  are  hysterical  polyuria  and  diabetes  insipidus  to  be 
differentiated  ? 

The  excessive  discharge  of  urine  that  is  sometimes  observed 
in  hysterical  patients  is  paroxysmal  rather  than  persistent ; 
and  does  not  constitute  the  essential  feature  of  the  disease,  but 
is  rather  an  incidental  symptom  of  a  malady  of  protean  feature. 

Glycosuria. 

What  is  glycosuria  ? 

By  glycosuria  is  meant  the  presence  of  grape-sugar  or  glucose 
in  the  urine.  The  condition  may  be  transient,  intermittent  or 
'persistent.  Thus,  it  may  follow  the  ingestion  of  excessive 
amounts  of  sugar  or  starch  or  of  chloral  or  other  drugs,  inhala- 
tion of  chloroform,  or  traumatism,  or  attend  infectious  diseases 
and  nutritional  diseases,  e.  g.,  chronic  malaria,  exophthalmic 
goiter,  akromegaly,  myxedema,  acute  and  chronic  suppurative 
appendicitis.  It  is  the  distinguishing  feature  of  diabetes  mel- 
litus. 

Diabetes  Mellitus. 

What  are  the  clinical  features  of  diabetes  mellitus  ? 

Diabetes  mellitus  is  a  morbid  condition  attended  by  the  dis- 
charge of  large  quantities  of  urine  characterized  by  the  per- 
sistent presence  of  a  varying  quantity  of  glucose.  It  is  a 
metabolic  disorder  of  adult  life,  though  at  times  observed 
in  the  young.     Males  suffer  rather  more  commonly  than  fe- 


284  ESSENTIALS    OF    DIAGNOSIS. 

males.  The  disease  occurs  sometimes  in  connection  with  cer- 
ebral disease,  sometimes  with  disease  of  the  pancreas  or  of  the 
liver,  sometimes  in  women  at  the  menopause  and  sometimes 
as  a  sequel  of  infectious  diseases  or  of  exhausting  labors;  it 
sometimes  attends  or  follows  pregnancy;  but  it  is  commonly 
unassociated  with  any  evident  visceral  disease.  In  many  cases 
there  is  a  racial  or  family  predisposition  or  a  gouty  or  rheumatic 
diathesis.  In  not  a  few  instances  the  advent  of  the  disease  has 
been  preceded  by  grief,  anxiety  or  profound  emotion.  The 
course  of  the  affection  is  ordinarily  slowly  progressive ;  excep- 
tionally it  is  acute  and  rapidly  fatal. 

Among  the  earliest  symfptoms  is  a  gradual  failure  of  health, 
with  a  sense  of  fatigue  disproportionately  great.  Often  there 
is  mental  alteration,  especially  irritability  of  temper.  It  may 
be  observed  that  the  patient  is  passing  an  excessive  quantity  of 
urine,  examination  of  which  shows  it  to  be  pale  in  color,  of  a 
sweetish,  fragrant  odor,  usually  of  high  specific  gravity,  and 
chemically  containing  glucose.  The  proportion  of  sugar  varies, 
being  increased  by  indulgence  in,  and  diminished  by  abstinence 
from,  sugars  and  starches.  At  the  same  time,  there  is  increased 
thirst,  together  with  the  ingestion  of  large  quantities  of  fluids. 
The  urine  dissolves  gentian-violet.  The  appetite  is  also  wont  to 
be  excessive,  and  large  quantities  of  food  are  taken.  Constipa- 
tion is  the  rule,  though  exhausting  diarrhea  may  occur.  The 
skin,  mouth  and  throat  are  dry.  A  sweetish  taste  is  perceived. 
The  breath  may  exhale  a  fragrant,  a  balsamic,  an  ethereal  odor, 
or  an  odor  of  chloroform.  The  teeth  become  carious,  the  gums 
spongy  and  loose.  Boils  and  carbuncles  are  common.  Per- 
sistent furunculosis,  without  obvious  cause,  should  always 
awaken  a  suspicion  of  diabetes.  In  women,  pruritus  vulvae,  and, 
in  men,  excoriations  about  the  meatus  urinarius  have  been 
observed.  The  blood,  dried  and  fixed  on  glass  slides,  does  not 
stain  with  1%  aqueous  solution  of  Congo-red.  It  changes  the 
color  of  a  weak  alkaline  solution  of  methylene-blue  to  a  yellow- 
ish-green or  yellow.  Symptoms  of  peripheral  neuritis,  with 
abolition  of  the  knee-jerks  and  ataxia  may  appear.  Bilateral 
sciatic  neuritis  sometimes  develops.  Failure  of  sexual  vigor  is 
sometimes  an  early  symptom.     Emaciation  and  debility  may 


DIABETES    MELLITUS.  285 

ultimately  become  extreme.  Exceptionally  an  appearance  of 
perfect  health  is  preserved.  Some  have  distinguished  two 
groups  of  cases,  those  with  a  tendency  to  emaciation,  and  those 
with  a  tendency  to  obesity. 

Sometimes,  there  is  sense  of  chilliness  and  the  temperature  is 
subnormal.  Gangrene  from  vascular  occlusion  may  result  and 
bring  about  a  fatal  issue.  After  death  the  bladder  is  often 
found  hypertrophied.  Cataract  not  rarely  develops  in  the 
course  of  diabetes.  Eetinitis  also  may  occur  and  retinal  hem- 
orrhage take  place.  Nephritis  is  sometimes  superadded.  Death 
commonly  results  from  an  intercurrent  affection,  such  as  pul- 
monary tuberculosis  or  pneumonia.  Sometimes  coma  appears, 
w^ith  or  without  delirium  and  convulsions.  Coma  is  in  many 
cases  preceded  for  a  few  days  by  the  appearance  in  the 
urine  of  acetone  and  diacetic  acid,  concurrently,  it  may  be, 
with  diminution  in  the  amount  of  urine  and  in  the  percent- 
age of  sugar.  Obstinate  constipation  also  may  be  a  fore- 
runner. 

What  is  Moore's  test  for  the  presence  of  glucose  in  the  urine  ? 

The  simplest  test  for  the  presence  of  sugar  in  the  urine  is 
Moore's  test.  To  a  moderate  quantity  of  urine  in  a  test-tube 
half  as  much  liquor  potassse  is  added.  The  mixture  is  heated. 
If  sugar  be  present  in  greater  proportion  than  0.3  per  cent.,  a 
sherry-wine  color  results.  If  a  drop  or  two  of  nitric  acid  be 
added,  the  brownish  color  disappears  and  the  odor  of  molasses 
becomes  perceptible.  Other  substances  than  sugar  respond 
similarly  in  color  ;  so  that  the  test  cannot  be  infallibly  relied 
upon. 

What  is  Boettger's  test  ? 

To  a  small  quantity  of  urine  in  a  test-tube  is  added  about  an 
equal  quantity  of  liquor  potassse,  and  then  a  small  pinch  of  bis- 
muth subnitrate.  The  mixture  is  heated  ;  if  sugar  be  present  a 
black  precipitate  of  metallic  bismuth  is  thrown  down.  Sulphur 
compounds  precipitate  black  sulphides,  so  that  albumin,  if  pre- 
sent, should  first  be  removed  by  precipitation  and  filtration.  If 
the  reaction  fails  to  take  place,  the  presence  of  sugar  in  signifi- 
cant quantity  can  safely  be  excluded. 


286  ESSENTIALS    OF    DIAGNOSIS. 

What  is  Trommer's  test  ? 

To  a  moderate  quantity  of  urine  in  a  test-tube  a  smaller 
quantity  of  liquor  potassee,  and  then  a  few  drops  of  a  ten  per 
cent,  solution  of  cupric  sulphate  are  added.  If  heat  be  applied, 
an  orange-red  precipitate  of  cuprous  oxide  is  thrown  down  if 
sugar  be  present. 

What  is  Fehling's  test? 

Two  solutions  are  used.  One  consists  of  an  ounce  of  cupric 
sulphate  and  sufficient  water  to  make  fifteen  ounces  ;  the  otlier 
of  five  ounces  of  crystallized  Rochelle  salts,  three  ounces  of  a 
solution  of  sodium  hydrate  having  a  specific  gravity  of  1.34,  and 
sufficient  water  to  make  fifteen  ounces.  When  the  test  is  to  be 
made,  equal  quantities  of  the  two  test-solutions  are  heated  in  a 
test-tube.  The  urine  is  then  slowly  added.  Should  no  orange- 
red  precipitate  result,  the  presence  of  sugar  can  be  excluded. 

Fehling's  test  can  be  applied  for  quantitative  analysis  by  em- 
ploying solutions  of  which  a  known  volume  will  be  reduced  by 
a  definite  quantity  of  glucose  10  cu.  cm.  of  Fehling's  solution 
will  be  reduced  b}^  5  mgm.  of  glucose. 

What  is  the  fermentation-test  ? 

If  a  bit  of  baker's  yeast  be  added  to  urine  containing  sugar, 
fermentation  takes  place,  carbon  dioxide  and  alcohol  being  gen- 
erated. In  making  a  quantitative  examination  the  specific 
gravity  is  taken  and  recorded  ;  eight  ounces  of  urine  are  intro- 
duced into  a  pint  bottle,  a  piece  of  compressed  yeast  about  the 
size  of  a  walnut  added,  and  the  bottle  closed  by  a  perforated 
cork,  and  placed  in  a  warm  place  (from  86°  to  90°  F.)  for  four 
or  five  hours  or  longer.  The  urine  is  then  permitted  to  cool, 
and  its  specific  gravity  is  again  taken.  Each  degree  of  loss  of 
specific  gravity  represents  about  one  grain  of  sugar  to  the  ounce, 
or  the  total  number  of  degrees  lost  multiplied  by  0.23  will  give 
the  percentage  of  sugar.  Einhorn's  fermentation-saccnarimeter 
is  so  graduated  as  to  indicate  the  approximate  percentage  of 
sugar  by  the  volume  of  carbon  dioxid  given  off  from  a  meas- 
ured quantity  of  urine. 

What  are  the  tests  for  acetone  ? 

1.  To  4  or  5  cu.cm.  of  urine  are  added  a  few  drops  of  a  fresh 


DIABETES    MELLITUS.  287 

solution  of  sodium  nitroprussid,  and  then  a  strong  solution  of 
sodium  hydroxid.  If  acetone  be  present  a  red  color  appears  in 
from  five  to  ten  minutes,  giving  place  to  a  purple  or  violet  on 
addition  of  acetic  acid.  2.  About  4  cu.cm.  (1  dram)  of  solution 
of  potassic  hydrate,  containing  1  gram  (15  grains)  of  potassium 
iodid,  are  placed  in  a  test-tube  and  boiled.  An  equal  volume 
of  urine  is  then  cautiously  poured  in,  so  as  to  float  on  the  sur- 
face of  the  alkaline  liquid.  At  the  point  of  contact  a  ring  of 
phosphates  will  form,  which,  if  acetone  be  present,  will  in  a  few 
minutes  be  colored  yellow  and  studded  with  crystals  of  iodo- 
form. 3.  Tincture  of  iodin  or  compound  solution  of  iodin  is 
added  to  the  urine  or  a  distillate  thereof  and  then  sufficient 
ammonia  to  occasion  a  deep-black  precipitate.  This  disappears 
gradually  if  acetone  be  present  and  is  replaced  by  a  yellowish 
precipitate  of  iodoform,  which  may  be  recognized  by  its  odor 
and  by  the  appearance  microscopically  of  six-sided  tables  or 
stars. 

What  is  a  convenient  test  for  diacetic  acid  ? 

Solution  of  ferric  chlorid  is  slowly  added  to  the  fresh  urine ; 
the  phosphates  thus  precipitated  are  removed  by  filtration,  and 
more  ferric  chlorid  is  added.  If  aceto-acetic  acid  is  present, 
the  urine  becomes  wine-red.  The  test  must  then  be  repeated 
with  urine  previously  boiled.  If  the  boiled  urine  gives  no  reac- 
tion with  the  iron-solution,  or  only  a  slight  coloration,  and  if 
acetone  is  likewise  found  to  be  present,  it  maybe  concluded  that 
diaceturia,  a  forerunner  of  diabetic  coma,  exists. 

How  are  diabetes  insipidus  and  diabetes  mellitus  to  be  differ- 
entiated ? 

The  diagnostic  distinction  between  diabetes  meUitus  and 
diabetes  insipidus  is  the  presence  or  absence  of  sugar  in  the 
urine,  of  which  the  specific  gravity  is  lower  in  the  latter  than 
in  the  former.  The  occurrence  of  boils,  of  itching  of  the  skin, 
of  cataract  and  of  gangrene,  the  presence  of  a  sweetish  taste 
and  of  a  fragrant  breath,  encountered  in  saccharine  diabetes, 
are  wanting  in  insipid  diabetes.  The  prognosis  in  the  case  of 
diabetes  insipidus  is  more  favorable  than  in  that  of  diabetes 
mellitus. 


288  ESSENTIALS    OP   DIAGNOSIS. 


Cystitis, 

What  are  the  symptoms  of  cystitis? 

The  mucous  meinbran'3  of  the  bladder  may  undergo  in- 
flammation in  the  course  of  constitutional  disorders,  or  as  the 
result  of  local  irritation  or  infection.  Cystitis  gives  rise  to 
pain  in  the  hypogastrium,  a  frequent  desire  to  urinate,  followed 
by  the  evacuation  of  small  quantities  of  urine,  attended  with 
burning  pain.  The  last  drops  of  urine  passed  are  opaque  and 
viscid.  The  quantity  of  urine  voided  does  not  in  the  aggregate 
exceed  the  normal.  When  the  cystitis  is  acute  the  reaction  of 
the  secretion  is  acid  ;  in  chronic  cystitis  the  urine  is  alkaline  ;  the 
urine  is  turbid  and  precipitates  a  dense,  copious  sediment ;  it  is 
albuminous  in  a  degree  proportionate  to  the  quantity  of  pus  con- 
tained. Examined  microscopically  the  sediment  is  found  to  be 
made  up  of  pus-corpuscles,  pavement  epithelial  cells  and  mucus. 
In  the  earliest  stages  of  acute  cystitis  the  urine  may  contain 
blood  ;  in  chronic  cystitis,  crystals  of  the  triple  ammonio-mag- 
nesium  phosphate  may  be  found.  The  walls  of  the  bladder  be- 
come thickened,  its  cavity  reduced  in  size,  its  lining  membrane 
ribbed.  The  dangerous  sequelae  of  cystitis  are  ureteritis,  pye- 
litis, hydronephrosis  and  suppurative  nephritis,  dependent  upon 
extension  of  the  inflammatory  process. 

How  are  cystitis  and  nephritis  to  be  differentiated  ? 

Pain  in  the  hypogastrium  is  a  feature  when  there  is  acute 
cystitis.  If  pain  attend  acute  nephritis,  it  is  referred  to  the 
loins.  Urine  is  passed  less  frequently  and  in  smaller  quantities 
when  acute  nephritis  exists  than  is  the  case  in  acute  cystitis. 
The  urine  of  cystitis  is  the  more  distinctly  purulent ;  that  of 
nephritis,  the  more  distinctly  albuminous.  In  cases  of  nephritis, 
the  urine  contains  casts  of  the  uriniferous  tubules.  The  urine 
of  simple  cystitis  never  contains  tube-casts.  The  alkalinity  of 
the  urine,  the  presence  of  pus,  and  the  absence  of  tube-casts, 
in  addition  to  the  absence  of  other  phenomena,  such  as  edema, 
dyspnea,  anemia,  cardiac  hypertrophy,  distinguish  chronic  cys- 
titis from  chronic  nephritis. 


VESICAL    CALCULUS PYELITIS.  289 

Vesical  Calculus, 

To  what  symptoms  does  a  vesical  calculus  give  rise  ? 

The  presence  of  a  calculus  in  the  bladder  gives  rise  to  irrita- 
tion and  inflamraation.  In  addition  to  the  signs  of  cystitis — 
frequent,  burning  discharge  of  small  quantities  of  urine  of  alka- 
line or  acid  reaction — there  occur  attacks  of  vesical  tenesmus, 
with  complete  obstruction  to  the  discharge  of  urine,  with  pain 
referred  to  the  glans  penis,  followed  by  the  presence  of  blood  in 
the  urine.  Careful  examination,  by  means  of  a  sound  or  the 
cystoscope,  may  furnish  conclusive  evidence.  A  vesical  calcu- 
lus may  not  only  excite  cystitis,  but  it  may  also  give  rise  to 
inflammation  and  dilatation  of  the  ureters  and  pelves  of  the  kid- 
neys and  to  hydronephrosis. 

Neoplasms  of  the  Bladder, 

To  what  symptoms  do  neoplasms  of  the  bladder  give  rise? 

"VYhen  the  lining  of  the  bladder  is  the  seat  of  new-growths, 
hemorrhage  is  of  frequent  occurrence,  together  with  paroxysms 
of  vesical  tenesmus.  The  urine  usually  contains  cellular  evi- 
dence of  the  presence  of  a  neoplasm,  while  cystoscopic  exami- 
nation may  afford  ocular  demonstration  of  the  fact. 

Pyelitis. 

What  are  the  symptoms  of  pyelitis  ? 

Inflammation  of  the  mucous  membrane  of  the  pelvis  of  the 
kidney  may  arise  in  the  course  of  acute  infectious  diseases,  may 
result  by  extension  from  the  urethra,  through  the  bladder  and 
ureters,  or  from  the  presence  of  a  calculus  or  a  new-growth. 
Pyelitis  may  be  tuberculous.  There  is  pain  in  the  loin.  The 
urine,  the  reaction  of  which  remains  acid,  precipitates  a  copious 
sediment  principally  constituted  of  pus,  with  some  epithelial 
cells.  From  time  to  time  the  urine  may  contain  blood.  If 
suppuration  be  pronounced  there  may  be  chills  and  fever,  with 
anemia  and  emaciation. 
19 


290  ESSENTIALS    OF    DIAGNOSIS. 

In  cases  of  tuberculosis,  tubercle-bacilli  may  be  found  in  the 
urine,  and  there  may  be  evidences  of  tuberculous  disease  else- 
where. It  is  said  that  bacilli  morphologically  indistinguishable 
from  tubercle-bacilli  and  presenting  the  same  color-reactions  are 
sometimes  found  in  the  urine  of  healthy  persons.  The  numbers 
are  smaller,  and  the  organisms  are  less  constantly  present  than 
in  cases  of  tuberculosis,  and  the  inoculation-test  proves  them 
to  be  innocuous. 

How  are  pyelitis  and  cystitis  to  be  differentiated  ? 

The  pain  of  pyelitis  is  referred  to  the  lumbar  region  ;  that  of 
cystitis  to  the  hypogastric  region.  Small  quantities  of  urine  are 
frequently  evacuated  in  case  of  cystitis ;  neither  quantity  nor 
frequency  is  altered  in  uncomplicated  pyelitis.  When  there  is 
cystitis,  the  urine  is  most  likely  to  be  alkaline  in  reaction  ;  when 
there  is  pyelitis,  it  is  usually  acid. 

Eenal  Inadequacy. 

What  is  renal  inadequacy? 

Some  individuals  never  pass  more  than  a  normal  or  slightly 
less  than  normal  quantity  of  urine  of  low  specific  gravity  and 
containing  abnormally  little  urea,  even  though  they  should 
partake  of  an  excess  of  fluids.  The  condition  has  been  termed 
renal  inadequacy.  The  symptoms  are  vague  and  indefinite. 
There  is  a  sense  of  ill-being,  an  undue  readiness  of  fatigue,  and 
a  lowered  resistance  to  disease.  Patients  so  affected  bear  opera- 
tive interference  badly.  There  may  be  slight  edema,  but  the 
urine  contains  neither  albumin  nor  casts. 


Displacements  of  the  Kidney. 

To  what  displacements  is  the  kidney  subject  ? 

The  kidney  may  undergo  several  degrees  of  displacement  and 
in  several  ways.  It  may  be  congenitally  fixed  in  some  unusual 
situation,  as  behind  the  umbilicus,  in  front  of  the  vertebral 
column,  in  the  iliac  fossa,  at  the  sacro-iliac  junction — displaced 
kidney.      Secondly,  the    kidney  may  acquire   greater  or  less 


RENAL   CALCULUS.  291 

freedom  of  movement,  though  practically  confined  within  its 
normal  situation — movable  kidney.  Finally,  provided  with  a 
mesonephron,  it  may  possess  a  wide  range  of  movement— ;/?oa/- 
ivg  kidney. 

Congenital  displacement  of  the  kidney  usually  is  unattended 
with  symptoms  and  escapes  recognition  during  life.  Undue 
mobility  of  the  kidney  is  much  more  common  in  women  than 
in  men,  and  on  the  right  side  than  on  the  left.  It  may  be  in- 
duced by  constriction  of  the  waist,  alternately  repeated  ab- 
dominal distention  and  relaxation,  traumatism,  heavy  lifting, 
and  adjacent  disease,  and  it  may  occur  as  part  of  a  general 
splanchnoptosis. 

The  condition  may  be  unattended  with  symptoms,  but  fre- 
quently there  is  pain  in  the  loin,  with  a  sense  of  dragging 
and  discomfort.  Neurotic  manifestations,  neurasthenia,  hys- 
teria, hypochondriasis,  are  not  uncommon  accompaniments. 
The  organ  may  be  merely  palpable,  or  it  may  be  found  quite 
out  of  place,  although  susceptible  of  reposition.  Floating  kid- 
ney may  be  attended  with  crises  of  abdominal  pain,  with  chills, 
fever,  nausea,  vomiting,  collapse.  By  twisting  of  the  ureter, 
urine  may  accumulate  in  the  renal  pelvis,  to  be  evacuated  when 
the  quantity  has  reached  a  certain  limit. 

Renal  Calculus. 

To  what  symptoms  does  a  renal  calculus  give  rise  1 

A  calculus  in  the  pelvis  of  the  kidney  occasions  constant  dull 
pain  in  the  loin,  aggravated  into  great  intensity  in  paroxysms, 
superinduced  by  active  physical  exercise  or  by  concussion. 
Following  the  paroxysm  the  urine  contains  blood.  In  the  in- 
terval the  urine  contains  pus.  If  the  calculus  enter  the  ureter, 
efforts  at  its  expulsion  give  rise  to  excruciating  pain  in  the 
course  of  the  ureter,  with  retraction  of  the  corresponding  tes- 
ticle, numbness  of  the  thigh,  nausea  and  vomiting.  When  a 
renal  calculus  is  a  cause  of  obstruction  to  the  flow  of  urine, 
hydronephrosis  or  atrophy  of  the  kidney  may  result.  Renal 
calculi  may  be  constituted  of  uric  acid,  of  oxalates,  of  phos- 
phates and  less  commonly  of  cystin  and  xanthin. 


292  ESSENTIALS   OF   DIAGNOSIS. 

Acute  Nephritis. 

What  are  the  clinical  features  of  acute  nephritis  ? 

Acute  inflammation  of  the  kidney  is  common  in  association 
with  acute  infectious  diseases — especially  scarlatina,  erysipelas, 
small-pox  and  yellow  fever.  It  may  follow  exposure  to  cold,  or 
result  from  the  ingestion  of  toxic  substances.  It  sometimes 
develops  in  the  course  of  pregnancy,  and  occasionally  in  con- 
junction with  cutaneous  lesions,  such  as  burns.  The  kidneys 
are  large  and  smooth  and  reddened.  The  inflammation  par- 
ticularly involves  the  parenchyma  of  the  organs.  The  occur- 
rence of  acute  nephritis  may  be  manifested  by  a  chill,  which 
is  followed  by  fever,  by  pains  in  the  loins,  by  headache, 
perhaps  with  nausea,  vomiting  and  diarrhea.  The  face  (nota- 
bly the  eyelids)  is  pufly ;  the  extremities  are  swollen  and 
edematous.  The  excretion  of  urine  is  diminished  to  a  mini- 
mum ;  there  may  be  actual  suppression.  The  urine  presents  a 
smoky,  reddish,  turbid  aspect ;  its  specific  gravity  is  high  ;  it  is 
deficient  in  urea,  but  it  contains  a  decided  quantity  of  albumin 
and  hyaline  and  epithelial  casts,  and  blood-casts,  as  well  as 
free  blood-corpuscles.  The  symptoms  of  uremia  may  super- 
vene ;  to  the  headache,  nausea  and  vomiting,  are  added  derange- 
ment of  vision,  delirium,  convulsions  and  coma.  In  the  course 
of  several  weeks,  the  symptoms  gradually  subside,  though  the 
accompanying  anemia  yields  but  obstinately,  while  the  urine 
may  continue  albuminous  for  a  long  time,  perhaps  permanently. 
Inflammations  of  the  serous  membranes  are  frequent  in  the 
course  of  acute  nephritis. 

Chronic  Parenchymatous  Nephritis. 

What  are  the  symptoms  of  chronic  parenchymatous  nephritis  ? 
Recovery  from  acute  inflammation  of  the  kidney  may  be 
imperfect ;  repeated  attacks  may  leave  a  permanently  damaged 
organ  ;  finally  an  inflammation  of  the  parenchyma  of  the  kidney 
may  be  insidious  and  essentially  chronic  from  the  outset. 
However  produced,  the  symptows  are  variable.  The  essential 
characteristic  is  the  persistent  presence  of  a  considerable 
quantity  of  albumin  in  the  urine,  together  with  granular,  hyaline 


CHRONIC    INTERSTITIAL    NEPHRITIS.  293 

or  fiitty  tube-casts.  The  quantity  of  urine  may  scarcely  deviate 
from  the  normal.  A  characteristic  variety  of  retinitis  may  be 
detected  with  the  ophthalmoscope.  Edema  of  the  face  and 
extremities  occurs,  anemia  is  manifest,  assimilation  is  im- 
paired, the  arterial  tension  is  heightened,  and  the  heart  becomes 
enlarged.  Ascites  is  common.  Edema  of  the  larynx  or  lungs, 
or  effusions  into  the  pleurae  or  pericardium  may  take  place  sud- 
denly or  gradually.  Headache,  impaired  vision,  somnolence, 
convulsions  and  coma,  from  uremia,  may  develop.  Individuals 
affected  with  chronic  parenchymatous  nephritis  badly  resist  dis- 
ease. The  probabilities  are  that  the  so-called  fatty  kidney  is 
but  a  modification  of  the  kidney  of  chronic  parenchymatous 
nephritis,  dependent  upon  secondary  degeneration.  The  symp- 
toms of  both  conditions  are  much  alike.  In  the  secondary 
degeneration,  the  presence  of  fatty  casts  and  of  oil-globules  is 
characteristic. 

Amyloid  Kidney. 

What  are  the  clinical  features  of  amyloid  disease  of  the  kidney  ? 

Amyloid,  lardaceous  or  waxy  disease  of  the  kidney  depends  upon 
a  peculiar  hyaline  degeneration  of  the  coats  of  the  renal  capil- 
laries, which  is  often  associated  with  some  degree  of  chronic 
parenchymatous  nephritis,  and  with  amyloid  degeneration  in 
other  organs,  such  as  the  liver,  the  spleen  and  the  intestine. 
The  symptoms  are  practically  those  of  the  associated  condition. 
In  addition  to  edema,  albuminuria,  the  presence  of  tube-casts 
in  the  urine,  heightened  arterial  tension  and  cardiac  hyper- 
trophy, there  may  be  a  peculiarly  waxy  complexion,  diarrhea, 
and  painless  enlargement  of  the  liver,  without  ascites  and  jaun- 
dice. Amyloid  degeneration  results  usually  in  consequence  of 
protracted  suppuration  or  ulceration,  or  of  syphilis. 

Chronic  Interstitial  Nephritis. 

What  are  the  symptoms  of  chronic  interstitial  nephritis  ? 

The  interstitial  structure  of  the  kidney  participitates,  in  some 
degree,  in  every  inflammation  of  the  organ.     The  involvement 


294  ESSENTIALS    OF    DIAGNOSIS. 

becomes  especially  obvious  in  the  late  stages  of  all  forms  of 
nephritis.  In  some  cases,  however,  the  interstitial  connective 
tissue  undergoes  hyperplasia  from  the  outset,  ultimately  con- 
tracting and  giving  rise  to  a  diminution  in  the  size  of  the  organ, 
which  becomes  small,  red,  granular  ;  the  capsule  is  thickened  ; 
on  attempting  to  remove  it  the  adherent  cortex  tears.  This 
chronic  interstitial  nephritis  is  often  but  one  part  of  a  widely 
distributed  arterio-capillary  fibrosis.  The  principal  symptom  re- 
ferable to  the  kidneys  is  frequent  micturition,  the  urine  being 
considerably  increased  in  quantity,  of  a  low  specific  gravity,  and 
containing  a  trace  of  albumin  and  hyaline  and  granular  tube- 
casts.  Albumin  and  casts  are  sometimes  only  to  be  found  by 
repeated,  careful  examination.  There  is  little  or  no  edema, 
unless  dilatation  of  the  heart  develop.  There  is  shortness  of 
breath.  The  arterial  tension  is  high  and  the  heart  is  hypertro- 
phied.  The  second  sound  of  the  heart  is  accentuated.  The  ap- 
petite is  impaired,  digestion  is  deranged  and  vomiting  may  occur. 
There  is  sometimes  persistent  diarrhea.  Retinitis,  papillitis, 
and  hemorrhages  may  occur.  Death  usually  results  from  ure- 
mia or  cerebral  hemorrhage.  The  commonest  causes  of  chronic 
interstitial  nephritis  are  alcoholism,  gout  and  lead-poisoning. 

What  are  the  symptoms  of  uremia  ? 

Uremia  is  an  auto-intoxication,  which  sometimes  arises  in  the 
course  of  disease  of  the  kidneys  and  is  dependent  upon  the  re- 
tention in  the  fluids  of  the  body  of  certain  products  that  it  is 
the  function  of  the  kidneys  to  remove.  It  may  be  acute  or 
chronic.  Uremia  gives  rise  to  headache,  vertigo,  nausea,  vom- 
iting, diarrhea,  motor  palsy,  tremulousness,  dyspnea,  dilatation 
of  the  pupil,  altered  vision,  delirium,  somnolence,  convulsions 
and  coma.  Effusions  and  pulmonary  edema  frequently  accom- 
pany the  condition.  The  temperature  may  be  subnormal.  It 
has  exceptionally  been  observed  to  be  febrile.  The  body  and 
breath  exhale  a  musty  odor.  Uremia  is  one  of  the  gravest  com- 
plications of  disease  of  the  kidneys. 

How  are  a  uremic  seizure  and  a  paroxysm  of  epilepsy  to  be 
differentiated? 

Probably  dependent  upon  analogous  conditions  of  irritation, 


ABSCESS    OF    THE    KIDNEY.  295 

there  is  little  difference  between  the  convulsions.  The  onset  of 
an  epileptic  attack  is  sudden,  attended  with  a  cry  and  biting  of 
the  tongue,  and  possibly  preceded  by  an  aura  ;  the  convulsions 
of  uremia  are  usually  preceded  by  headache,  vertigo  and  nausea, 
and  occur  without  sound  or  injury  to  the  tongue.  The  urine 
may  contain  albumin  during  or  after  an  epileptic  paroxysm,  but 
casts  are  present  as  well  when  the  convulsions  are  uremic.  Epi- 
leptic seizures  are  far  more  likely  than  uremic  convulsions  to 
have  been  and  to  be  repeated.  A  knowledge  of  the  previous 
history  of  the  case  simplifies  the  diagnosis. 

How  are  uremia  and  insolation  to  be  differentiated  ? 

The  failure  on  the  part  of  the  skin  as  well  as  on  the  part  of 
the  kidneys  to  eliminate  certain  excrementitious  products  may 
in  cases  of  insolation  give  rise  to  phenomena  resembling  those 
presented  by  uremia  ;  but  in  the  former  the  temperature  attains 
a  height  never  seen  in  the  latter,  while  the  season  of  the  year 
at  which  the  accident  happens,  as  well  as  the  attendant  circum- 
stances, makes  the  diagnosis  clear. 

Abscess  of  the  Kidney. 

What  are  the  symptoms  of  abscess  of  the  kidney  ? 

Suppuration  may  take  place  in  the  kidney  as  the  result  of  an 
acute  infectious  nephritis,  as  a  part  of  a  general  pyemia,  or  in 
consequence  of  traumatism.  When  pus  has  formed,  the  symp- 
toms  occasioned  are  those  to  which  imprisoned  pus  usually  gives 
rise  :  rigors,  hectic  fever,  sweats,  emaciation.  The  urinary 
secretion  will  be  altered  in  accordance  with  the  intensity  and 
extent  of  the  causative  or  associated  nephritis.  In  the  urine 
may  be  found  albumin,  pus,  tube-casts  and  blood-corpuscles. 
There  may  be  pain  and  tenderness  in  the  region  of  the  kidney. 
If  the  accumulation  of  pus  attains  considerable  proportions  it 
may  give  rise  to  a  palpable  tumor,  ^vith  fluctuation,  in  the  loin. 
The  abscess  may  rupture  into  the  pelvis  of  the  kidney,  into  an 
adjacent  viscus,  into  the  abdominal  cavity  ;  or  the  pus  may 
make  its  way  out  through  the  abdominal  wall. 


296  ESSENTIALS    OF    DIAGNOSIS, 


Perinephric  Abscess. 

What  are  the  clinical  features  of  perinephric  abscess  ? 

Suppuration  may  take  place  in  tlie  perinephric  connective 
tissue  as  a  result  of  an  extension  of  inflammation  in  the  pelvis 
or  in  the  structure  of  the  kidney  or  as  a  result  of  blows  or 
injuries.  The  condition  is  to  be  recognized  by  the  existence 
of  pain  and  tenderness  in  connection  with  a  bogg}?^,  fluctu- 
ating tumor  in  the  loin,  associated  with  chills,  fever,  sweats 
and  emaciation.  The  tumor  is  not  movable,  and  cannot  be 
separated  from  the  kidney.  Exploratory  puncture  may  detect 
the  presence  of  pus.  Such  an  abscess  may  burrow  and  find 
an  exit  above  or  below  Poupart's  ligament,  in  the  loin,  into  the 
kidney,  ureter  or  bladder,  into  the  peritoneum,  intestines  or 
into  a  lung. 

How  are  a  perinephric  and  a  renal  abscess  to  be  differentiated  ? 

An  abscess  in  the  loin  developing  in  the  course  of  pyemia  is 
more  likely  to  be  renal  than  perinephric  ;  an  abscess  following 
traumatism  is  more  likely  to  be  perinephric  than  renal ;  while 
disease  of  the  pelvis  or  of  the  kidney  may  give  rise  to  one  or  the 
other.  The  pus  of  a  perinephric  abscess  is  more  likely  than  that 
of  a  renal  abscess  to  burrow  and  point  at  some  distant  spot.  In 
cases  of  renal  abscess  evidences  of  disease  are  likely  to  appear 
in  the  urine  ;  there  may  be  pus  with  albumin  and  tube-casts. 

Tuberculosis  of  the  Kidney. 

What  are  the  clinical  features  of  tuberculosis  of  the  kidney? 

Miliary  tubercles  may  be  developed  in  the  kidneys  in  common 
with  other  organs,  as  a  part  of  an  acute  miliary  tuberculosis. 
More  usually,  when  the  kidney  is  tuberculous,  the  foci  are  more 
extensive,  and  exhibit  a  tendency  to  undergo  caseation.  The 
kidney  is  rarely  the  exclusive  seat  of  tuberculosis.  As  a  rule, 
other  portions  of  the  genito-urinary  tract  are  likewise  involved, 
and  not  uncommonly  the  lungs  as  well.  Miliary  tuberculosis  of 
the  kidney  does  not  give  rise  to  symptoms  apart  from  those  of 


HYDRONEPHROSIS.  297 

the  general  coiulitioii  of  which  it  is  but  an  incident.  In  the  more 
locaUzed  lesion,  the  symptoms  are  vague.  There  may  be  pain 
in  the  loin,  "with  tenderness  ;  exceptionally  a  tumor  is  discover- 
able on  physical  examination  ;  the  urine  may  contain  pus  and 
detritus,  in  which  tubercle-bacilli  can,  perhaps,  be  found  ;  some- 
times there  is  hematuria  ;  there  may  be  hectic  fever.  Ulti- 
mately emaciation  sets  in,  exhausting  sweats  take  place  and 
the  vitality  fails.  Tuberculosis  of  the  kidney  is  more  frequent 
in  the  young  than  in  the  old,  in  males  than  in  females. 

Malignant  Disease  of  the  Kidney. 

What  are  the  clinical  manifestations  of  malignant  disease  of 
the  kidney  ? 

Malignant  disease  of  the  kidney  is  sarcomatous  or  carcino- 
matous. Sarcoma  ma}^  be  congenital  or  it  may  appear  during 
childhood.  Carcinoma  rarely  develops  before  forty.  The 
classical  symptoms  are  tumor,  pain  and  hematuria. 

The  swelling  occupies  one  of  the  loins,  and  is  separated  from 
the  anterior  abdominal  wall  by  the  large  intestine.  The  pain  is 
dull  and  heavy,  with  acute  exacerbations.  Hematuria  is  not 
constant.  Its  .absence  is  of  less  significance  than  w^ould  be  its 
presence.  In  addition,  the  appetite  fails  ;  there  may  be  nausea 
or  vomiting,  constipation  or  diarrhea  ;  emaciation  sets  in  ;  and 
cachexia  develops.  Edema  of  the  lower  extremities  and  ascites 
may  result  from  pressure  on  the  veins. 

Hydronephrosis. 

What  is  hydronephrosis? 

When  there  exists  at  any  part  of  the  genito-urinary  tract  an 
obstruction  to  the  flow  of  urine,  such  as  may  be  occasioned  by  a 
calculus,  a  neoplasm,  an  enlarged  prostate  gland,  a  kink  or  a 
twist  in,  or  pressure  from  without  upon,  a  ureter,  fluid  accumu- 
lates behind  the  point  of  obstruction,  and  causes  dilatation. 
The  condition  is  designated  as  hydronephrosis.  It  is  some- 
times congenital  and  it  may  be  either  unilateral  or  bilateral. 
If  the  obstruction  be  situated  in  the  urethra  or  at  the  ori- 
fice of  the  bladder,  the  bladder,  the  ureters,  and  the  pelves  of 


298  ESSENTIALS   OF   DIAGNOSIS. 

the  kidneys  all  become  thickened  and  dilated.  If  but  one  ureter 
is  obstructed  tlie  corresponding  pelvis  sutlers.  The  dilatation 
of  the  pelvis  gives  rise  to  compression  and  atrophy  of  the  renal 
parenchyma.  Sometimes  the  fluid  resembles  pale  urine  of  low 
specific  gravity  ;  at  other  times  it  contains  pus.  In  the  latter 
case  the  condition  is  designated  pyonephrosis.  The  symptoms 
are  ill-defined.  There  may  be  dull  pain,  a  sense  of  fulness,  and 
a  fluctuant  tumor  in  one  or  the  other  loin,  attended  perhaps 
with  the  periodic  discharge  of  large  quantities  of  urine,  as  the 
obstruction  is  temporarily  relieved,  with  a  corresponding  reces- 
sion of  the  symptoms.  There  may,  in  addition,  be  rigors,  hectic 
fever,  sweats  and  emaciation.  Constipation  due  to  pressure 
upon  the  bowel,  is  not  uncommon  in  cases  of  hydronephrosis. 
The  urine  may  be  normal,  except  at  such  times  as  the  periodic 
copious  discharges  take  place,  when  pus  or  other  matters  may 
be  found  present.  In  cases  of  double  hydronephrosis  there  is 
great  liability  to  the  sudden  development  of  uremia. 

Hydatid  Cyst  of  the  Kidney. 

What  are  the  symptoms  occasioned  by  an  hydatid  cyst  of  the 
kidney  ? 

The  kidneys  are  relatively  a  common  seat  of  hydatid  cysts. 
Such  a  cyst  in  connection  with  the  kidney  may  give  rise  to  a 
fluctuating  tumor  in  the  loin  or  in  the  lateral  region  of  the 
abdomen,  yielding  the  characteristic  thrill  on  percussion,  and 
occasioning  symptoms  dependent  upon  pressure  ;  or  prior  to 
surgical  exploration,  it  may  not  give  rise  to  definite  symptoms 
and  may  elude  physical  exploration.  Under  any  circumstances 
a  diagnosis  may  not  be  possible,  unless  the  contents  of  the  cyst 
find  their  way  into  the  genito-urinary  tract  and  are  evacuated  ; 
when  the  detection  of  the  booklets  in  the  urine  leaves  no  room 
for  doubt.  The  recognition  of  an  additional  cyst  in  another 
situation  may  facilitate  the  diagnosis. 

How  are  an  hydatid  cyst  of  the  kidney  and  hydronephrosis 

to  be  differentiated  ? 
An   hydatid   cyst   of  the   kidney   and   hydronephrosis   both 
occasion  a  fluctuating  renal  tumor,  but  the  peculiar  thrill  on 


THE    NERVOUS    SYSTEM.  299 

percussion  that  characterizes  many  hydatid  cysts  is  wanting  in 
all  cases  of  water-logged  kidney.  Hydronephrosis  is  dependent 
upon  some  form  of  genito-uriuary  obstruction  ;  such  a  condition 
bears  no  relation  to  the  development  of  an  hydatid  cyst.  The 
periodic  discharge  of  a  large  quantity  of  fluid,  with  a  temporary 
disappearance  of  the  tumor,  is  characteristic  of  hydronephrosis  ; 
should  a  discharge  of  fluid  take  place,  in  connection  with  an 
hydatid  cyst,  microscopic  examination  will  reveal  the  character- 
istic booklets  in  tlie  urine. 


THE  NERVOUS  SYSTEM. 

How  is  a  study  of  diseases  of  the  nervous  system  to  he  ap- 
proached ? 
By  an  investigation  of  motion,  sensation,  reflex  action,  nutri- 
tion, electric  reaction  and  cerebral  functions. 

How  may  motion  be  affected  ? 

The  power  of  muscular  movement  may  be  impaired  or  lost ; 
motility  may  be  exaggerated  ;  or  coordination  may  be  impaired. 
Complete  loss  of  muscular  power  is  called  %)aTalysis;  partial 
loss,  pctresis.  Motor  over-action  is  seen  in  spasm  and  con- 
vulsion.    Incoordination  gives  rise  to  ataxia. 

The  power  of  voluntary  motion  is  impaired  or  lost  in  destruc- 
tive disease  at  any  part  of  the  motor  tract,  from  the  cerebral 
cortex  to  the  end-plates.  Movement  may  be  interfered  with  by 
disease  of  the  muscle  itself,  or  of  an  adjacent  joint ;  or  abstained 
from  on  account  of  the  pain  that  it  causes  in  a  joint  or  muscles. 

Loss  of  motor  power  confined  to  one  side  of  the  body  is  called 
hemiplegia ;  if  bilateral,  diplegia;  limited  to  the  lower  extremities, 
paraplegia;  localized  to  a  member,  monojjlegia. 

Hemiplegia  is  usually  dependent  upon  a  unilateral  cerebral 
lesion  ;  it  may  possiblj^  be  caused  by  a  unilateral  lesion  seated 
in  the  upper  portion  of  the  cord. 

Diplegia  may  be  a  result  of  symmetrical  bilateral  cerebral 
lesions,  or  of  a  lesion  in  a  situation  where  the  motor  tracts  are 
close  together  ;  like  hemiplegia,  it  may  possibly  be  caused  b}^  a 
lesion  in  the  upper  portion  of  the  spinal  cord. 


300  ESSENTIALS    OP   DIAGNOSIS. 

Paraplegia  is  almost  invai'ial)ly  a  result  of  disease  of  the  cord. 

Monoplegia  is  a  result  of  a  circumscribed  lesion  of  the  brain, 
usually  in  or  near  the  motor  cortex.  Any  form  of  paralysis 
may  be  simulated  by  hysteria. 

Spasm  or  convulsion  is  indicative  of  irritation  at  any  part 
of  the  motor  tract.  It  may  occur  in  acute  disease,  cerebral 
(hemorrhage,  embolism,  thrombosis)  or  constitutional  (tetanus, 
hydrophobia)  ;  in  chronic  irritative  disease  (cortical  softening, 
tumor)  ;  or  it  may  be  a  symptom  of  nutritional  disease  (epilepsy), 
or  of  functional  disease  (hysteria)  ;  it  may  also  occur  in  disease 
not  strictly  nervous  (uremia). 

Ataxia  is  the  result  of  derangement  of  the  conducting  fibers 
or  the  coordinating  centers  in  the  cord  or  cerebellum.  Loss  of 
tactile  sensation  also  gives  rise  to  ataxia.  Defective  equilibra- 
tion may  result  from  disease  of  the  internal  auditory  apparatus. 

What  are  the  varieties  of  sensation  ? 

Common  or  tactile  sensibility,  the  pain-sense,  the  tempera- 
ture-sense, the  muscular  sense,  the  stereognostic  sense ;  special 
sensation :  smell,  vision,  taste  and  hearing. 

How  may  sensation  be  affected? 

Sensation  may  be  impaired,  retarded,  lost,  perverted  or 
heightened.  Impairment  of  sensation  is  hijpesthesia ;  loss  of  sen- 
sation is  anesthesia;  heightening  of  sensation,  hyperesthesia; 
perversion  of  sensation,  paresthesia.  Alterations  in  sensation 
are  dependent  upon  derangement  in  the  course  of  the  sensory 
path.  As  the  lesion  may  be  destructive  or  irritative,  so  may 
the  symptoms  be  those  of  diminished  sensation,  of  supersensi- 
bility,  or  of  perverted  sensation.  One  or  the  other  variety  of 
sensation  may  be  affected  w^ithout  involvement  of  all. 

What  are  the  varieties  of  reflexes  ? 

Super^cial  or  cutaneous,  and  muscular  or  deep. 

What  are  the  principal  superficial  reflexes 

The  plantar,  the  gluteal,  the  cremasteric,  the  abdominal, 
the  epigastric,  the  conjunctival,  the  reaction  of  the  iris  to  light, 
and  to  cutaneous  irritation. 


THE  NERVOUS  SYSTEM.  301 

What  are  the  principal  varieties  of  deep  reflexes  ? 

The  knee-jerk,  ankle-clonus,  the  tendo-Aehillis  jerk,  the 
biceps-jerk,  and  the  elbow-jerk. 

How  are  the  reflexes  altered  in  disease  ? 

They  may  be  exaggerated,  enfeebled  or  entirely  lost. 

The  superficial  retlexes  are  exaggerated  when  the  influence  of 
the  inhibitory  apparatus  is  removed,  or  when  the  activity  of 
the  reflex  apparatus  of  the  spinal  cord  is  heightened  ;  the  deep 
reflexes  are  exaggerated  under  similar  conditions,  and  likewise 
when  degeneration  has  taken  place  in  the  cerebro-spinal  motor 
tract.  Both  superficial  and  deep  reflexes  are  lost  when  the 
reflex  arc  is  interrupted  at  any  point  in  its  course — sensory 
nerve,  reflex  center  in  the  cord,  and  motor  nerve. 

How  is  the  nutrition  affected  by  disease  of  the  nervous  system  ? 

Trophic  changes  often  attend  disease  of  the  nervous  system. 
Bedsores  sometimes  form.  Muscles  may  waste.  A  paralyzed 
limb  is  edematous  and  its  temperature  is  subnormal  ;  in  chil- 
dren the  growth  of  paralyzed  parts  is  retarded.  Decided  altera- 
tions in  joints  may  take  place.  The  skin  sometimes  becomes 
glossy.  Trophic  changes  are  most  marked  in  degenerative  dis- 
ease of  the  nerves  and  of  the  gray  matter  of  the  cord,  especially 
of  the  anterior  horns.  The  nutrition  of  a  palsied  member  slow'ly 
sufters. 

How  are  the  electric  reactions  affected  by  disease  ? 

The  normal  response  of  muscle  and  nerve  to  both  the  voltaic 
and  faradic  currents  may  be  enfeebled  or  exaggerated— a  quan- 
titative change ;  or  the  response  of  nerve  to  both  faradism  and 
voltaism,  and  of  muscle  to  faradism  may  be  enfeebled  or  lost, 
wiiile  the  response  of  muscle  to  voltaism  persists  and  may  be 
exaggerated  and  is  altered  in  its  polar  relations — a  qualitative 
change^  the  reaction  of  degeneration. 

l^ormally,  the  response  of  muscle  to  voltaic  stimulation  is 
most  ready  upon  application  of  the  kathode  and  making  (closure) 
of  the  current ;  least  ready  upon  application  of  the  kathode  and 
breaking  (opening)  of  the  current.  Eesponse  upon  anodal  clo- 
sure and  anodal  opening  is  less  ready  than  that  of  kathodal 
closure,  more  ready  than  that  of  kathodal  opening. 

The  sequence:   (1)  K.Cl.C.  ;    (2)  |;^  qc.'-     (^)  ^•^•^'  '  i^ 


302  ESSENTIALS    OF    DIAGNOSIS. 

called  the  normal  formula.  A  deviation  from  this  sequence 
gives  a  formula  expressive  of  the  reaction  of  degeneration— a 
qualitative  change.  Quantitative  changes  take  place  in  simple 
wasting  dependent  upon  disuse  or  disease  of  the  muscle  or  of  an 
adjacent  joint,  or  upon  interruption  in  the  motor  path  between 
the  cerebral  cortex  and  the  ganglion-cells  of  the  anterior  horns 
of  the  spinal  cord  ;  qualitative  changes  take  place  in  degenera- 
tive muscular  wasting  dependent  upon  lesions  of  nerve  or  cord, 
between  the  motor  end-plates  and  the  ganglion-cells  of  the  ante- 
rior horns  inclusive. 

How  are  the  cerebral  functions  affected  by  disease  of  the 
nervous  system  ? 
Delirium,  headache  and  vertigo  may  appear.  Vision,  hear- 
ing, taste  or  smell  may  be  perverted,  excessively  acute,  im- 
paired or  lost ;  memory  may  be  enfeebled ;  speech  may  be 
altered  or  lost ;  articulation  may  be  defective  ;  the  emotions 
may  be  affected  ;  consciousness  may  be  deranged  ;  the  higher 
mental  powers  may  suffer  deterioration. 

Neuritis, 

How  may  neuritis  be  classified  ? 

Into  perineuritis,  interstitial  neuritis  and  parench3nnatous 
neuritis.  Neuritis  may  be  acute  or  chronic  ;  it  may  affect  one 
nerve  or  many. 

What  are  the  causes  of  neuritis? 

Inffamuiation  of  a  nerve  may  result  from  local  injury  or  com- 
pression, from  adjacent  inflammation,  from  exposure  to  cold, 
or  from  the  influence  of  irritating  matters  circulating  in  the 
blood,  such  as  alcohol,  metallic  poisons  (lead,  arsenic,  mercury), 
the  toxic  products  of  infectious  diseases  (diphtheria,  syphiUs, 
influenza),  and  of  perverted  metabolism  (diabetes,  nephritis, 
gout).  Injury,  comj)ression,  adjacent  inflammation  and  expos- 
ure to  cold  give  rise  to  circumscribed  neuritis;  irritants  in  the 
blood,  as  a  rule,  to  multiple  neuritis. 

What  are  the  symptoms  of  neuritis  ? 
When  a  nerve  is  inflamed,  hyperesthesia,  paresthesia  and 


MULTIPLE    NEURITIS.  303 

anesthesia,  pain,  tingling,  numbness  in  the  peripheral  distribu- 
tion and  tenderness  in  the  course  of  tlie  nerve-trunk  in  turn 
appear,  with  impairment  or  loss  of  motion.  If  the  exciting  con- 
ditions be  maintained,  nerves  degenerate  and  muscles  waste 
and  the  skin  becomes  glossy.  Exposure  to  cold  is  a  cause  of 
inflammation  of  the  facial  nerve ;  rheumatism,  gout  and  dia- 
betes, of  inflammation  of  the  sciatic ;  lead-poisoning,  of  inflam- 
mation  of  branches  of  the  radial,  median  and  ulnar;  pressure, 
of  inflammation  of  the  musculo-spiral ;  syphilis  and  alcoholism, 
of  inflammation  of  the  peripheral  nerves  of  the  extremities ; 
alcohol,  tobacco,  syphilis,  of  inflammation  of  the  optic  nerve. 
Obstinate  neuralgias  are  sometimes  dependent  upon  neuritis. 
Acute  neuritis  is  attended  with  fever  and  other  constitutional 
phenomena. 

With  what  conditions  may  neuritis  be  confused  ? 

With  subacute  rheumatism,  with  neuralgia  and  with  disease 
of  bone.  The  pain  occurring  in  the  course  of  diseases  of  the 
spinal  cord  may  be  mistaken  for  an  evidence  of  neuritis. 

How  is  the  diagnosis  of  neuritis  to  be  made  ? 

The  symptoms  are  limited  to  the  distribution  of  one  or  more 
nerves  and  there  is  tenderness  on  pressure.  When  neuralgia  is 
not  dependent  on  neuritis,  there  are  certain  tender  points,  the 
pain  shoots  and  intermits,  and  loss  of  sensation  does  not  result. 
Pain  of  spinal  origin  is  not  local  in  distribution  or  associated 
with  tenderness. 

Multiple  Neuritis. 

What  are  the  causes  of  multiple  neuritis? 

Multiple  or  disseminated  neuritis^  ov  'polyneuritis^  maj'  be  a  com- 
plication or  a  sequel  of  infectious  diseases,  such  as  syphilis, 
diphtheria  and  influenza ;  it  may  develop  in  the  course  of 
posterior  spinal  sclerosis  or  it  may  appear  as  a  part  of  anes- 
thetic leprosy ;  it  may  be  due  to  metallic  poisoning,  as  with 
lead,  mercury,  arsenic ;  it  may  occur  endemically,  as  the  dis- 
ease known  as  kak-ke  or  beri-beri;  the  most  common  causes, 
however,  are  chronic  alcoholism  and  exposure  to  wet  and 
ppld. 


304 


ESSENTIALS     OF     DIAGNOSIS, 


What  are  the  symptoms  of  multiple  neuritis? 

If  multiple  neuritis  set  in  suddenly,  it  may  present  rigor, 
elevation  of  temperature  and  other  febrile  symptoms. 

It  is  attended  with  numbness,  tingling,  pain,  tenderness  and 
loss  of  power  in  the  distribution  of  the  nerves  affected,  usually 
those  of  the  extremities.  Paralysis,  wasting  and  impairment 
of  sensation  soon  follow.  There  may  be  wrist-drop,  foot-drop, 
abolition  of  reflexes  and  ataxia. 

Trophic  changes  occur  in  the  skin,  nails  and  hair.  Edema 
is  not  uncommon.  The  wasted  muscles  present  reactions  of 
degeneration.  Secondary  contractions  may  take  place  in  the 
unopposed  muscles. 

Fig.  43. 


Multiple  neuritis,  wrist-drop  and  foot  drop.    (Gowers.) 

Nerves  of  special  sense,  as  the  olfactory,  the  optic,  the  audi- 
tory and  the  gustatory,  may  suffer. 

How  are  spinal  pachymeningitis  and  multiple  neuritis  to  be 
differentiated? 

Spinal  pachymeningitis  is  usually  cervical ;  the  symptoms  are 
thus  especially  referable  to  the  upper  extremities.  There  is  also 
an  absence  of  tenderness  in  the  course  of  the  nerves,  while  pain 
radiating  from  the  spinal  column  is  the  rule. 

How  does  acute  myelitis  differ  from  multiple  neuritis  ? 

Myelitis  usuall}^  involves  a  limited  area  of  the  spinal  cord  in 
the  dorsal  or  lumbar  region.  The  symptoms  are  thus  mani- 
fested in  the  lower  half  of  the  body  and  constitute  the  type  of 
paraplegia.     The  action  of  the  sphincters  is  impaired.     There 


SCIATICA.  305 

is  anesthesia,  with  a  zone  of  h3'peresthesia  and  but  little  pain. 
The  paralyzed  muscles  waste  rapidly.  The  reflexes  are  mostly 
exaggerated  in  the  parts  supplied  by  the  nerves  that  arise  below 
the  affected  area  of  the  cord. 

Sciatica. 

What  are  the  causes  of  sciatica  ? 

Sciatica  is  usually  dependent  upon  inflammation  of  the  sciatic 
nerve. 

It  is  more  common  in  males  than  in  females  and  in  middle 
life  than  at  any  other  period.  It  may  be  primary,  developing 
in  gouty,  diabetic,  or  rheumatic  persons  or  after  exposure  to 
wet  and  cold,  or  following  injury,  or  as  the  result  of  pressure 
from  sitting  on  the  edge  of  a  chair ;  or  secondary,  in  conse- 
quence of  compression  by  tumors  in  the  course  of  the  nerve, 
within  or  without  the  pelvis,  or  as  a  result  of  extension  from 
adjacent  disease,  as  of  the  hip-joint. 

What  are  the  symptoms  of  sciatica  ? 

Sciatica  is  attended  with  pain  and  tenderness  in  the  course 
and  distribution  of  the  sciatic  nerve,  increased  by  movement. 
There  are  certain  tender  points :  1,  at  the  posterior  inferior 
spine  of  the  ilium  ;  2,  at  the  sciatic  notch  ;  3,  at  the  middle  of 
the  thigh  ;  4,  on  the  posterior  aspect  of  the  knee  ;  5,  below  the 
head  of  the  fibula  ;  G,  behind  the  external  malleolus  ;  and  7,  on 
the  dorsum  of  the  foot.  There  are  also  paresthesia,  tingling, 
formication  and  numbness. 

In  aggravated  cases,  the  affected  muscles  waste  and  present 
degenerative  reactions.  There  may  also  be  fibrillary  contrac- 
tions and  muscular  cramps. 

Primary  sciatica  is  rarely  bilateral. 

With  what  conditions  may  sciatica  be  confounded  ? 

With  sciatic  neuralgia,  with  disease  of  the  hip-joint,  and  with 
disease  of  the  spinal  cord  or  cauda  equina. 
How  is  the  differential  diagnosis  to  be  made  ? 

Sciatic  neuralgia  occurs  in  debilitated  and  anemic  persons, 
with  neuralgia  elsewhere  ;  the  pain  is  intermittent,  and  in  the 
20 


306  ESSENTIALS    OF    DIAGNOSIS. 

distribution  rather  than  in  the  course  of  the  nerve  ;  it  may  be 
induced  by  movement,  but  is  not  otherwise  aggravated  thereby  ; 
there  is  spontaneous  pain  rather  tlian  tenderness. 

Disease  of  the  hip-joint  may  give  rise  to  pain  about  the  hip- 
joint  and  knee  ;  but  there  is  no  tenderness  in  the  course  of  the 
nerve  ;  and  investigation  will  disclose  the  obvious  cause  of  the 
symptoms. 

The  pain  to  which  disease  of  the  spinal  cord  or  of  the  cauda 
equina  gives  rise  is  bilateral  in  distribution  ;  it  is  not  attended 
with  tenderness  in  the  course  of  the  nerve  ;  but  it  is  associated 
with  additional  symptoms  indicative  of  its  origin. 

How  are  primary  and  secondary  sciatica  to  be  differentiated? 

The  pain  and  tenderness  in  the  course  of  the  nerve  in  primary 
sciatica  are  wanting  when  the  sciatica  is  secondary  ;  the  pain 
is  then  rather  in  the  distribution  of  the  nerve  ;  other  symptoms, 
and  careful  examination  per  rectum,  if  need  be,  may  le^d  to  the 
detection  of  an  adequate  cause  for  the  pain. 


Facial  Hemiatrophy. 

"What  is  facial  hemiatrophy  ? 

Atrophy  of  one  side  of  the  face  may  begin  in  childhood  or  it 
may  follow  blows  or  injuries  later  in  life.  It  is  believed  to  be 
dependent  upon  disease  of  the  trigeminal  nerve.  Both  the  soft 
parts  and  the  bone  are  involved,  including  sometimes  also  the 
tongue,  and  the  hair  and  the  teeth  on  the  affected  side  may  fall 
out.  The  disease  sometimes  extends  beyond  the  median  line, 
and  sometimes  appears  also  in  other  parts  of  the  body.  The 
condition  must  be  discriminated  from  enlargement  of  one  side 
of  the  face. 


Paralysis  of  the  Facial  Nerve. 

What  are  the  causes  of  paralysis  of  the  facial  nerve? 

The  facial  nerve  may  be  paralyzed  by  lesions  above  its  nucleus 
(supra-nuclear),  by  lesions  of  the  nucleus  (nuclear),  or  by  lesions 
in  the  course  of  the  nerve  (infra-nuclear).     The  first  is  repre- 


PARALYSIS    OP   THE    FACIAL    NERVE 


307 


sented  by  the  paralysis  of  hemiplegia.  The  nucleus  and  the 
root-fibers  may  be  damaged  as  a  result  of  hemorrhacre,  softeninc:. 
degeneration,  or  inflammation,  or  by  a  new-growth.  The  nerve 
may  suffer  from  compression  by  tumors,  from  traumatism,  from 
neuritis  (primary  or  secondary).  The  most  common  cause  of 
facial  paralysis  is  exposure  to  cold. 

What  are  the  symptoms  of  paralysis  of  the  facial  nerve  ? 

In  facial  paralysis  of  nuclear  or  infra-nuclear  origin  all  of 
the  muscles  of  one  side  of  the  face  are  paralyzed  ;  the  face  is 
rendered  asymmetrical  by  the  unantagonized  action  of  the 
muscles  of  the  opposite  side  ;  the  eye  upon  one  side  remains 
open  and  cannot  be  closed  ;  the  lower  lid  is  relaxed  and  epiphora 
results  ;  the  forehead  on  that  side  is  smooth  and  cannot  be 
wrinkled  ;  the  angle  of  the  mouth  droops  ;  saliva  dribbles  from 
the  corner  of  the  mouth  ;  the  normal  furrows  are  obliterated  ; 
the  lips  cannot  be  puckered,  as  in  whistling,  nor  elevated,  as  in 
displaying  the  teeth  ;  associated  and  emotional  movements  are 

Fig.  44. 


Facial  paralysis.    The  figure  on  the  right  represents  an  attempt  to  close  the  eyes. 

(Gowers.) 

wanting  on  the  paralyzed  side.     Numbness  and  tingling  indi- 
cate involvement  of  filaments  of  the  fifth  nerve. 

The  affected  muscles  waste  and  reactions  of  degeneration 
develop.  If  complete  recovery  do  not  occur,  secondary  contrac- 
tion in  the  paralyzed  and  wasted  muscles  takes  place. 


308  ESSENTIALS    OF.  DIAGNOSIS. 

If  the  seventh  nerve  is  injured  between  the  geniculiite  gan- 
glion and  tlie  origin  of  the  chorda  tympani,  the  sense  of  taste  is 
lost  in  the  anterior  portion  of  the  tongue. 

How  are  facial  palsy  of  supra-nuclear  origin  and  that  of 
nuclear  or  infra-nuclear  origin  to  be  differentiated? 
Facial  palsy  of  supi-a-nuclear  origin  is  but  part  of  a  hemi- 
plegia, of  which  other  manifestations  will  be  evident ;  unlike 
what  takes  place  in  nuclear  and  infra-nuclear  disease,  the  orbi- 
cularis palpebrarum  and  the  occipito-frontal  muscles  escape.  In 
nuclear  and  infra-nuclear  palsy,  muscular  wasting  takes  place, 
with  degenerative  reaction,  which  is  not  the  case  in  palsy  of 
supra-nuclear  origin.  In  supra-nuclear  paralysis,  associated  and 
emotional  movements  of  the  face  are  symmetrically  performed  ; 
in  nuclear  or  infra-nuclear  palsy,  they  are  not. 


Paralysis  of  the  Phrenic  Nerve. 

What  are  the  causes  of  paralysis  of  the  phrenic  nerve  ? 

The  function  of  the  phrenic  nerve  may  be  interfered  with  by 
disease  of  the  spinal  cord  or  of  the  vertebrse,  by  the  pressure 
of  a  tumor  or  of  an  aneurism,  as  a  result  of  a  neuritis  or  of  a 
deep  wound  of  the  neck. 

To  what  symptoms  does  paralysis  of  the  phrenic  nerve  give 

rise? 

When  the  phrenic  nerve  is  paralyzed,  the  movements  of  the 
diaphragm  are  enfeebled  or  abolished.  If  the  nerve  on  one  side 
is  affected,  the  loss  of  power  is  not  marked  ;  but  if  both  are  par- 
alyzed, the  diaphragm  does  not  actively  descend  in  inspiration  ; 
instead  of  the  protusion  of  the  upper  portion  of  the  abdominal 
Avail,  there  is  retraction ;  dyspnea  is  induced  by  exertion ; 
cough  becomes  difficult. 

From  what  conditions  is  paralysis  of  the  phrenic  nerves  to 

be  differentiated? 

From  superior  intercostal  breathing,  from  inflammation  of  the 

diaphragm  and  from  degeneration  of  the  diaphragm.     In  the 

first  condition,  inspiratory  contraction  of  the  diaphragm  must 


PARALYSIS    OF    THE    M  USC  U  L  O- S  P  I  R  A  L    NERVE.     309 

be  carefully  looked  for  ;  in  the  second,  there  has  been  an  adja- 
cent inflammation,  most  probably  of  the  pleura  or  peritoneum  ; 
the  third  has  only  been  recognized  after  death. 

If  the  paralysis  of  the  phrenic  nerves  is  dependent  upon  dis- 
ease of  the  cord,  there  are  present  other  symptoms  than  inac- 
tivity of  the  diaphragm. 

Paralysis  of  the  Musculo-spiral  Nerve. 

What  are  the  causes  of  paralysis  of  the  musculo-spiral  nerve  ? 
The  musculo-spiral  nerve  may  be  paralyzed  as  a  result  of 
traumatism,  as  from  a  blow  or  when  the  humerus  is  fractured  ; 
the  nerve  maj'  be  compressed  b}^  callus,  by  contraction  of  the 
triceps  muscle,  or  by  the  head  of  a  crutch  in  the  axilla  ;  neuritis 
may  result  from  exposure  to  cold.  The  most  common  cause  of 
musculo-spiral  paralysis  is  pressure  by  the  head  on  the  arm 
during  sleep. 

How  is  paralysis  of  the  musculo-spiral  nerve  to  be  recognized  ? 

The  characteristic  symptom  of  paralysis  of  the  musculo-spiral 
nerve  is  loss  of  power  in  the  extensors  of  the  elbow  and 
wrist,  in  the  long  extensors  of  the  fingers  and  thumb,  and  in  the 
supinators.  There  is  wrist-drop  and  the  fingers  and  thumb 
cannot  be  extended.  From  the  want  of  antagonism  the  power 
of  flexion  is  also  enfeebled.  Subsequentl}^,  the  palsied  muscles 
may  present  reactions  of  degeneration. 

How  does  the  neuritis  of  lead-poisoning  differ  from  the  neu- 
ritis of  the  musculo-spiral  nerve  resulting  from  compres- 
sion or  traumatism? 

Both  are  attended  by  wrist-drop,  which  in  lead-poisoning  is 
bilateral,  in  compression-neuritis  unilateral.  In  the  former,  the 
onset  is  slow  and  gradual  and  the  action  of  the  supinators  is 
unimpaired  ;  in  the  latter,  the  onset  is  acute  and  supination 
cannot  be  performed.  A  blue  line  on  the  gums  attends  lead- 
poisoning  ;  careful  chemic  examination  during  the  administra- 
tion of  potassium  iodide  may  detect  lead  in  the  urine  ;  while 
in  musculo-spiral  palsy  a  cause  of  a  different  kind  is  readily 
ascertainable. 


310  ■         ESSENTIALS    OF    DIAGNOSIS. 

Neuromata. 

To  what  symptoms  do  neuromata  give  rise? 

Tumors  in  the  course  of  nerves  may  be  composed  of  nervous 
structure  or  be  heterologous.  They  may  be  hereditary,  con- 
genital, or  a  result  of  traumatism  ;  they  are  not  uncommonly 
seen  on  the  stumps  of  amputated  members.  The  symptoms 
that  such  growths  occasion  necessarily  depend  upon  their 
situation.  At  first  they  give  rise  to  irritation  and  heightened 
function,  as  evidenced  by  pain  and  spasm  ;  subsequently  they 
cause  abolition  of  function  and  paralysis. 

Upon  what  does  the  diagnosis  of  neuromata  depend  ? 

Upon  the  detection  of  a  tumor  and  the  obstinacy  of  symptoms 
referable  to  the  distribution  of  one  or  more  nerves. 

Neuralgia. 

What  are  the  clinical  features  of  neuralgia  ? 

Pain  in  the  course  of  a  nerve,  independent  of  neuritis,  appears 
most  commonly  in  adult  life,  in  anemic  and  ill-nourished  women 
of  emotional  temperament.  In  some  instances,  an  hereditary 
predisposition  can  be  traced.  Among  the  causes  of  neuralgia 
are  exposure  to  cold,  rheumatism,  gout,  malaria,  alcoholism, 
plumbism,  traumatism  and  peripheral  irritation. 

The  pain  occurs  in  paroxysms,  in  the  intervals  between  which 
some  sensitiveness  persists.  In  the  course  of  the  nerve  are  cer- 
tain tender  points — points  douloureux  of  Valleix.  Muscular 
spasm  sometimes  takes  place  in  the  distribution  of  the  motor 
nerve  corresponding  to  the  sensory  nerve  involved.  The  par- 
oxysm is  sometimes  attended  with  vomiting.  Yaso-motor  de- 
rangement and  trophic  changes  may  manifest  themselves  in  the 
course  of  the  disease.  Neuralgia  may  be  localized  to  a  single 
nerve  ;  it  may  progress  in  a  radiating  manner,  or  it  may  change 
its  seat  from  nerve  to  nerve. 

How  are  neuritis  and  neuralgia  to  be  differentiated  ? 

The  pain  of  neuralgia  is  intermittent  and  paroxysmal ;  that 
of  neuritis  is  continuous ;  in  neuritis  there  is,  in  addition,  ten- 


MIGRAINE.  311 

derness  in  the  course  of  the  nerve,  with  swelling.  Neuritis  is 
not  limited  to  sensory  nerves  ;  in  consequence,  muscular  weak- 
ness and,  later,  wasting  and  alterations  in  the  electrical  reac- 
tions are  manifest. 

What  are  the  symptoms  of  trigeminal  neuralgia  ? 

The  symptoms  of  neuralgia  of  the  fifth  nerve,  trigeminal  or  tri- 
facial neuralgia,  or  tic  douloureux,  depend  upon  its  distribution. 
One  or  several  branches  of  the  nerve  may  be  involved. 

Of  the  first  division,  the  supra-orbital  branch  is  most  com- 
monly affected.  Pain  is  felt  on  the  forehead,  on  the  eyelid,  in 
the  eye  and  on  the  side  of  the  nose.  There  are  supra-orbital, 
palpebral,  nasal  and  ocular  tender  points. 

Of  the  second  division  of  the  fifth  nerve,  the  infra-orbital 
branch  is  most  commonly  attacked  by  neuralgia.  Pain  is 
referred  to  the  cheek  and  ala  nasi,  between  the  orbit  and  the 
mouth.  There  are  infra-orbital,  nasal,  malar  and  gingival 
tender  points. 

The  pain  of  neuralgia  of  the  inferior  maxillary  nerve  is  referred 
to  the  parietal  eminence,  the  temple,  the  lower  jaw,  the  ear  and 
the  tongue.  There  are  inferior  dental,  temporal  and  parietal 
tender  points.  Sometimes  the  inferior  dental  and  the  auriculo- 
temporal branches  are  alone  involved. 

Migraine. 

What  are  the  clinical  features  of  migraine  ? 

Migraine,  hemicrania  or  sick  headache  is  a  paroxysmal  neurosis 
characterized  by  unilateral  headache,  associated  with  nausea, 
vomiting  and  derangement  of  vision  and  sensation.  It  is  more 
common  in  females  than  in  males  and  in  the  first  half  of  life 
than  at  any  other  time.  Frequently  a  neurotic  heredity  can  be 
traced,  some  members  of  the  same  family  presenting  migraine, 
epilepsy,  neuralgia,  insanity  or  some  other  neurosis. 

The  paroxysm  often  begins  with  some  sensory  disturbance, 
such  as  tingling  or  numbness  ;  or  with  a  perversion  of  vision, 
such  as  the  appearance  of  a  luminous  or  brightly  colored  object ; 
or  with  an  impairment  of  vision  usually  presenting  the  char- 


312  ESSENTIALS    OF    DIAGNOSIS. 

acters  of  hemianopsia  or  with  auditoiy  nianifustations,  such  as 
tinnitus  or  a  sudden  explosive  sound.  When  the  headache 
reaches  a  considerable  degree  of  intensity  nausea  and  T^omiting 
occur.  In  extreme  cases  motor  weakness  and  aphasia  are 
present.  The  headache,  at  the  beginning  of  the  disease  uni- 
lateral, may  subsequently  become  bilateral.  It  is  often  periodic, 
and  not  rarely  in  some  fixed  relation  with  menstruation,  which 
it  may  accompany,  or  precede  or  follow  at  a  certain  interval. 

It  may  sometimes  be  traced  to  reflex  influences,  such  as  may 
arise  from  gastric  disturbance  or  eye-strain.  These,  however, 
are  to  be  regarded  merely  as  excitants,  acting  upon  a  predis- 
posed uervous  system,  and  would  not  alone  be  effective. 

How  are  migraine  and  ordinary  headache  to  be  differentiated  ? 

Headache  may  arise  from  a  multiplicity  of  conditions— among 
others  from  neuralgia,  from  rheumatism,  from  gastro-intestinal 
derangement,  from  toxemia,  from  eye-strain,  from  anemia,  from 
hyperemia  and  from  organic  disease  of  the  brain.  It  is  un- 
associated  with  other  subjective  or  with  visual  manifestations  ; 
it  is  bilateral ;  it  is  not  paroxysmal ;  it  is  dependent  upon  other 
influences  than  is  migraine. 

Spinal  Meningitis. 

What  are  the  varieties  of  spinal  meningitis  ? 

Spinal  menimjitis  may  be  acute  or  ckronic ;  it  may  involve  the 
dura,  arachnoid  or  pia,  giving  rise  respectively  to  pachymenin- 
gitis, arachnitis  or  leptomeningitis;  it  may  be  simple,  purulent, 
tuberculous  or  hemorrhagic. 

What  are  the  causes  of  spinal  meningitis  ? 

Inflammation  of  the  spinal  meninges  may  result  from  an  ex- 
tension of  adjacent  inflammation,  from  traumatism,  from  ex- 
posure to  cold  and  wet ;  it  may  develop  in  the  course  of  infec- 
tious diseases,  or  as  a  manifestation  of  syphilis,  of  tuberculosis, 
of  pyemia  or  of  alcoholism. 

What  are  the  symptoms  of  acute  spinal  meningitis  ? 

Meningitis  may  set  in  abruptly  with  a  chill,  followed  by  ele- 
vation of  temperature,  pain  in  the  back  and  radiating  in  the  course 


CERVICAL    PACHYMENINGITIS.  313 

of  the  nerves,  liyperesthesia,  stiffness  and  spasmodic  contrac- 
tion of  various  muscles,  exaggerated  reflexes,  retention  of  urine 
and  constipation.  The  pain  is  intensilied  in  paroxysms.  The 
muscular  spasms  are  induced  by  efforts  at  movement.  The 
finger  drawn  over  the  skin  leaves  a  red  streak. 

"With  the  subsidence  of  the  acute  symptoms,  the  pain  may 
yet  remain,  but  the  manifestations  of  irritation  give  way  to 
those  of  paralysis  :  muscular  weakness  and  wasting,  anesthesia, 
abolition  of  reflexes  and  enfeeblement  of  the  sphincters.  The 
extent  and  distribution  of  the  symptoms  depend  upon  the  seat 
of  the  meningeal  inflammation. 

How  are  rheumatism  of  the  muscles  of  the  back  and  spinal 
meningitis  to  be  differentiated  ? 

Pain  may  accompany  dorsal  or  lumbar  rheumatism,  but  it  is 
not  radiating,  nor  is  it  attended  with  muscular  rigidity,  or  fol- 
lowed by  anesthesia,  loss  of  power  and  wasting. 

Cervical  Pachymeningitis. 

What  are  the  symptoms  of  cervical  pachymeningitis  ? 

Inflammation  of  the  dura  mater  in  the  cervical  region  is 
recognized  by  pain  and  stiffness  in  that  region,  with  shoot- 
ing pains  in  the  arms,  and  numbness,  and  impaired  sensibility, 
and  loss  of  power,  and  wasting.  The  over-extension  of  the 
hand,  with  flexion  of  the  fingers,  that  results  from  the  paralysis 
of  the  long  flexors  of  the  wrist  and  fingers,  and  of  the  inter- 
ossei  gives  rise  to  characteristic  deformity.  There  may  also  be 
weakness  of  the  lower  extremities. 

How  is  cervical  pachymeningitis  to  be  distinguished  from 
progressive   muscular   atrophy  and  subacute  anterior 
poliomyelitis  ? 
All  three   may  give  rise   to   wasting  and   weakness  in  the 
upper  extremities,  and  weakness  in  the  lower  ;   but  in  pachy- 
meningitis sensation  is    deranged,  the  wasting  is  irregular  in 
distribution,  and  there  have  at  some  time  been  stiffness  in  the 
muscles  of  the  neck,  and  pains  in  the  back  and  radiating  down 
the  arms  ;  while  spasm  and  sensory  symptoms  are  wanting  in 
progressive  muscular  atrophy  and  poliomyelitis. 


314  ESSENTIALS    OP    DIAGNOSIS. 

Hemorrhage  into  the  Spinal  Membranes. 

What  are  the  varieties  of  hemorrhage  into  the  spinal  men- 
inges ? 

Hemorrhage  may  take  place  between  the  dura  and  the  ver- 
tebrre,  being  then  extrameningeal ;  or  within  the  dura,  being  then 
intrameningedl.  Intrameningeal  hemorrhage  may  take  place 
between  the  dura  and  the  arachnoid,  being  then  siihdural;  or 
between  the  arachnoid  and  the  pia,  being  then  subarachnoid. 

What  are  the  causes  of  hemorrhage  into  the  spinal  meninges  ? 

Hemorrhage  into  the  membranes  of  the  cord  is  usually  a  result 
of  traumatism,  as  from  falls  or  blows,  or  of  violent  muscular 
activity,  as  during  convulsions  or  labor  ;  it  may  occur  in  the 
course  of  acute  infectious  diseases  or  as  a  manifestation  of  a 
hemorrhagic  diathesis  ;  or  an  aneurism  that  has  eroded  the 
vertebrae  may  rupture  and  empty  its  contents  into  the  spinal 
canal. 

What  are  the  symptoms  to  which  hemorrhage  into  the  spinal 
membranes  give  rise  ? 
Hemorrhage  into  the  spinal  meninges  is  marked  by  sudden, 
severe  pain  in  the  back,  to  which  are  soon  added  rigidity,  mus- 
cular spasm,  radiating  pains,  hyperesthesia,  retention  of  urine 
and  constipation  ;  should  death  not  occur,  these  symptoms  in 
turn  give  way  to  muscular  weakness,  anesthesia  and  derange- 
ment of  the  sphincters. 

How  are  spinal  meningitis  and  hemorrhage  into  the  spinal 
meninges  to  be  differentiated  ? 

The  onset  of  hemorrhage  is  sudden,  that  of  meningitis  gradual. 
Meningitis  is  from  the  outset  attended  with  elevation  of  tem- 
perature ;  in  hemorrhage,  the  temperature  rises  only  when  men- 
ingitis sets  in. 

Anemia  of  the  Spinal  Cord. 

What  are  the  manifestations  of  anemia  of  the  spinal  cord  ? 

Anemia  of  the  spinal  cord  may  be  part  of  a  general  anemia. 
There  is  no  definite  symptom  by  which  it  can  be  recognized. 


MYELITIS.  315 

Whatever  the  symptoms  to  which  it  may  give  rise,  they  are 
comprised  in  those  of  the  condition  of  which  the  spinal  anemia 
is  a  part.  Tliere  is  aching  in  the  legs  and  the  patient  fatigues 
readily.  There  may  be  wasting  of  the  extremities  and  para- 
plegia. 

Hyperemia  of  the  Spinal  Cord. 

What  are  the  symptoms  of  hyperemia  of  the  spinal  cord  ? 

The  clinical  recognition  of  hyperemia,  other  than  as  a  condition 
antecedent  to  inflammation  of  the  spinal  cord,  is  as  doubtful  as 
is  that  of  spinal  anemia.  A  diagnosis  of  hyperemia  is  justifiable 
when  symptoms  apparently  indicative  of  a  beginning  myelitis 
disappear  in  the  course  of  a  few  days. 

Myelitis. 

What  are  the  varieties  of  myelitis  ? 

Myelitis  may  be  acute^  suhacute  or  chronic;  it  may  be  trans- 
verse,  focal,  disseminated,  diffuse  or  centred;  or  it  may  involve 
only  the  anterior  horns  of  the  gray  matter. 

What  are  the  causes  of  myelitis  ? 

Myelitis  is  more  common  in  males  than  in  females.  It  may 
result  from  traumatism,  from  exposure  to  cold  and  wet,  from 
compression,  by  extension  from  adjacent  disease  and  in  the 
course  of  acute  infectious  diseases  ;  syphilis  may  be  a  cause  of 
myelitis. 

What  are  the  symptoms  of  acute  myelitis? 

The  symptoms  of  acute  myelitis  set  in  with  variable  abrupt- 
ness and  with  febrile  manifestations.  There  may  at  first  be 
pains  of  moderate  severity  in  the  back.  Soon,  there  is  loss  of 
motion  and  sensation  in  the  parts  supplied  by  the  nerves 
arising  from  the  cord  below  the  level  of  the  inflammation,  with 
a  girdle-sensation  and  a  zone  of  hyperesthesia  corresponding 
to  the  distribution  of  the  nerves  given  ofl"  at  the  upper  limit  of 
the  inflammation.  Grave  trophic  changes,  as  wasting  and  the 
formation  of  bed-sores,  may  take  place,  with  the  development 
of  the  reactions  of  deseneration.     The  reflexes  within  the  dis- 


316  ESSENTIALS    OF    DIAGNOSIS. 

tribution  of  the  nerves  arising  from  the  inflamed  area  are  lost ; 
those  below  are  exaggerated.  Control  of  the  sphincters  is 
lost. 

After  the  subsidence  of  the  acute  symptoms,  some  improve- 
ment slowly  takes  place,  greater  in  respect  to  sensation  than  in 
respect  to  motion.  Cystitis  and  consecutive  pyelonephritis  may 
develop.  Contractures  may  take  place.  The  inflammation  of 
the  cord  may  extend. 

How  are  acute  spinal  meningitis  and  acute  myelitis  to  be 
distinguished  from  one  another? 

The  two  are  likely  to  be  associated  ;  the  symptoms  of  the  one 
or  the  other,  however,  predominating.  Pain,  hyperesthesia 
and  muscular  spasm,  followed  by  anesthesia  and  palsy,  char- 
acterize acute  meningitis.  In  myelitis,  pain  and  hyperesthesia 
are  slight,  transient  and  circumscribed  ;  muscular  spasm  is  want- 
ing ;  and  wasting,  palsy,  anesthesia  and  derangement  of  the 
sphincters  appear  early. 

How  are  acute  myelitis  and  spinal  hemorrhage  to  be  differen- 
tiated ? 
The  onset  of  hemorrhage  is  more  abrupt  than  that  of  myelitis. 
Initial  fever  indicates  myelitis  rather  than  hemorrhage.  Hem- 
orrhage into  the  spinal  cord  is  soon  followed  by  myelitis,  and  the 
differentiation  then  becomes  impossible. 

Chronic  Myelitis 

What  are  the  causes  of  chronic  myelitis? 

Chronic  myelitis  is  more  common  in  males  than  in  females, 
and  in  early  and  middle  adult  life  than  at  any  other  period.  The 
same  causes  that  occasion  acute  myelitis  may  also  give  rise  to 
chronic  myelitis.  Thus  chronic  myelitis  may  follow  syphilis, 
repeated  exposure  to  cold  and  wet,  repeated  over-exertion,  com- 
pression of  the  cord,  chronic  alcoholism  and  lead-poisoning. 
Chronic  myelitis  may  be  a  sequel  of  acute  myelitis  or  of  chronic 
meningitis. 

What  are  the  symptoms  of  chronic  myelitis  ? 

The  symptoms  of  chronic  myelitis  vary  in  distribution  with 


C  II  II  O  X  I  C    .M  Y  E  L  ITI  S .  317 

the  localization  of  the  disease.  There  is  at  first  an  undue  readi- 
ness of  muscular  fatigue,  soon  progressing  to  weakness  and  fol- 
lowed by  actual  palsj'.  Sensation  is  deranged  ;  paresthesise  are 
common  ;  girdle-pain  may  appear.  The  reflexes  are  exaggerated. 
A  tendency  to  spasm  develops.  The  muscles  waste  and  present 
quantitatively  altered  electric  reactions,  which,  in  the  later 
stages  of  the  disease,  suffer  qualitative  change.  The  sjjhincters 
usually  participate  in  the  loss  of  motor  power. 

How  does  chronic  differ  from  acute  myelitis  ? 

The  symptoms  of  chronic  myelitis,  unlike  those  of  acute  mye- 
litis, are  slow  and  gradual  in  onset,  progressive  in  course,  irreg- 
ular in  distribution  and  unattended  with  febrile  reaction. 

What  are  the  distinctions  between  chronic  myelitis  and  pro- 
gressive muscular  atrophy? 
The  symptoms  of  chronic  myelitis  are  irregular  in  distribu- 
tion ;  the  manifestations  of  progressive  muscular  atroph}-  ap- 
pear somewhat  symmetrically.  Sensory  symptoms  constitute  a 
distinctive  feature  of  chronic  m3'elitis,  but  are  inconsiderable  or 
wanting  in  progressive  muscular  atrophy.  Exaggeration  of  re- 
flexes and  spasm  characterize  myelitis  rather  than  muscular 
atrophy.  Fibrillary  muscular  contractions  and  heightened 
mechanical  irritability  mark  progressive  muscular  atrophy. 

In  what  respects  does  chronic  myelitis  differ  from  lateral 
sclerosis  ? 
In  lateral  sclerosis,  sensation  is  not  deranged  ;  there  is  no 
girdle-sensation ;    and    the   action   of   the   sphincters  remains 
unimpaired. 

What  is  the  distinction  "between  chronic  myelitis  and  spinal 
pachymeningitis  ? 

Spinal  pachymeningitis  is  most  commonly  cervical  and  the 
symptoms  are  limited  to  the  upper  extremities  ;  myelitis  ir- 
regularly involves  all  four  extremities.  Pain  is  a  more  constant 
manifestation  of  pachymeningitis  than  of  myelitis. 


318  ESSENTIALS    OF    DIAGNOSIS. 

Acute  Anterior  Poliomyelitis. 

What  are  the  causes  of  acute  anterior  poliomyelitis  ? 

Acute  inflammation  of  the  anterior  horns  of  the  gray  matter 
of  the  spinal  cord  is  more  conmion  in  males  than  in  females, 
in  late  infancy  than  at  any  other  period  of  life,  and  in  summer 
than  in  winter.  It  follows  sudden  chilling  of  the  heated  hody  ; 
injuries  to  the  spine ;  acute  infectious  diseases  ;  over-exertion. 

What  are  the  symptoms  of  acute  anterior  poliomyelitis  ? 

Acute  anterior  poliomyelitis  may  set  in  abruptly,  with  convul- 
sions, vomiting,  diarrhea,  delirium,  headache,  dull,  heavy  pains 
in  the  back  and  in  the  extremities,  and  febrile  symptoms. 
Soon  extensive  palsy  appears,  followed,  after  a  variable  period, 
by  wasting  of  certain  groups  of  muscles.  There  may  have  been 
incontinence  of  urine  and  of  feces. 

In  the  course  of  several  weeks  the  original  extent  of  paralysis 
gradually  diminishes,  until  ultimately  the  loss  of  power  and  the 
wasting  are  limited  to  certain  parts  that  remain  permanently 
deficient  in  nutrition,  growth  and  function.  Sensibility  is  un- 
affected. 

Degenerative  reactions  of  nerve  and  muscle  develop  and  the 
reflexes  are  enfeebled  or  lost. 

What  are  the  distinctions  between  myelitis  and  poliomyelitis? 

The  permanent  palsy  is  more  extensive  in  myelitis  than  in 
poliomyelitis.  In  the  former  the  reflexes  are  exaggerated  ;  in 
the  latter,  enfeebled  or  lost.  Sensory  symptoms  characterize 
myelitis ;  not  poliomyelitis.  Bedsores  are  common  in  the 
former  ;  not  in  the  latter. 

How  are  the  paralysis  of  poliomyelitis  and  that  of  cerebral 
origin  to  be  differentiated? 

The  paralysis  of  poliomyelitis  may  be  limited  to  one  side  ;  but 
it  is  not  characteristically  hemiplegic.  It  is  attended  with 
wasting  and  the  reaction  of  degeneration  ;  cerebral  paralysis 
may  be  attended  with  wasting,  but  not  with  the  reaction  of  de- 
generation. Athetoid  movements  appear  in  the  course  of  palsy  of 
cerebral  origin  ;  not  in  the  course  of  the  palsy  of  poliomyelitis. 


ACUTE    ASCENDING    PARALYSIS.  319 

The  reflexes  are  exaggerated  in  cerebral  disease  ;  enfeebled  or 
lost  in  poliomyelitis. 

How  are  multiple  neuritis  and  anterior  poliomyelitis  to  be  dif- 
ferentiated ? 

Sensory  symptoms — tingling,  pain,  tenderness,  numbness  and 
anesthesia — as  seen  in  neuritis,  are  wanting  in  poliomyelitis. 
Multiple  neuritis  is  rather  symmetrical,  poliomyelitis  irregular 
in  distribution.  The  one  is  the  more  common  in  adults  ;  the 
other,  in  children. 

Acute  Ascending  Paralysis, 

What  are   the  symptoms  of  acute   ascending   paralysis  or 
Landry's  paralysis  ? 

The  nature  of  acute  ascending  paralysis  is  not  yet  known. 
The  disease  is  thought  to  depend  upon  a  toxic  influence  exerted 
upon  the  nervous  system.  It  arises  under  conditions  similar  to 
those  that  precede  acute  mj^elitis.  It  is  characterized  by  pro- 
gressive motor  paralysis,  beginning  in  the  lower  extremities  and 
gradually  extending  upwards.  The  power  of  movement  is  lost ; 
respiration,  deglutition,  and  articulation  are  interfered  with. 
Numbness  and  tingling  are  sometimes  present  at  the  onset  and 
followed  by  impairment  of  sensation.  The  reflexes  are  en- 
feebled. Trophic  changes  are  wanting.  The  sphincters  are 
usually  uninvolved.  The  spleen  is  enlarged.  Most  cases  termi- 
nate fatally. 

How  are  acute  myelitis  and  acute  ascending  paralysis  to  be 
differentiated  ? 

Febrile  symptoms,  anesthesia,  trophic  changes  and  involve- 
ment of  the  sphincters  do  not  attend  acute  ascending  paralysis 
(Landry's  disease).  Kecovery  from  acute  ascending  paralysis 
is  less  common  than  is  recovery  from  myelitis. 

How  is  acute  ascending  paralysis  to  be  distinguished  from 

multiple  neuritis  ? 

The  view  has  been  expressed  that  acute  ascending  paralysis 

is  dependent  upon  multiple  neuritis.     Acute  ascending  paral}'- 

sis,  however,  does  not  appear  in  all  four  extremities  at  once,  and 


3^ 


ESSENTIALS     )  F    DIAGNOSIS 


is  said  not  to  present  the  alterations  of  sensation,  tlie  muscular 
wasting  and  the  elevation  of  temperature  of  multiple  neuritis. 

What  is  the  distinction  between  acute  ascending  paralysis  and 
anterior  poliomyelitis  ? 
The  onset  of  acute  anterior  poliomyelitis  is,  while  that  of  acute 
ascending  paralysis  is  flot,  attended  with  febrile  manifestations. 
In  poliomyelitis,  the  paralyzed  muscles  waste  ;  in  ascending 
paralysis,  they  do  not.  Poliomyelitis  is  rarely  fatal ;  ascending 
paralysis  is  usually  fatal. 

Amyotrophic  Lateral  Sclerosis  —  Progressive 
Muscular  Atrophy— Glosso-Labio-Laryngeal 
Palsy. 

There  are  three  aflections  intimately  related  to  one  another  : 
amyotrophic  lateral  sclerosis,  progressive  muscular  atrophy  and 
glosso-lahio-laryngeal  palsy.  The  pathologic  lesions  are  similar 
in  all :  a  degenerative  process  in  the  gray  matter  and  in  the 
conducting  paths.  The  symptoms  of  the  three  aflections  differ 
according  to  the  situation  of  the  disease  in  the  gray  matter, 
and  according  to  whether  the  change  begins  first  in  the  graj'- 
matter  and  then  involves  the  white  or  vice  versa. 

If  the  white  matter  of  the  lateral  columns  is  first  involved, 
with  partial  or  with  subsequent  invasion  of  the  gray  matter  of 
the  anterior  horns,  amyotrophic  lateral  sclerosis  results.  If  the 
gray  matter  of  the  cord  be  first  involved,  the  symptoms  of  pro- 
gressive muscular  atrophy  appear  ;  while  if  the  process  extend 
to  or  originate  in  the  gra}^  matter  of  the  medulla  the  symptoms 
are  those  of  bulbar  palsy,  superadded  or  occurring  isolated. 

What  are  the  causes  of  amyotrophic  lateral  sclerosis,  progres- 
sive muscular  atrophy  and  chronic  bulbar  palsy  ? 
In  many  cases,  no  cause  can  be  determined  ;  in  others  the 
symptoms  have  been  preceded  by  mental  strain,  by  exposure  to 
cold  and  wet,  by  concussion,  by  syphilis,  by  metallic  poisoning, 
as  with  lead,  mercury  or  arsenic,  and  b}^  acute  diseases ;  in  some 
there  is  an  indirect  neurotic  heredity.     All  three  affections  are 


AMYOTROPHIC    LATERAL    SCLEROSIS.  321 

more  common  in  males  than  in  females,  and  in  middle  life  than 
at  any  other  period. 

What  are  the  symptoms  of  amyotrophic  lateral  sclerosis  ? 

Amyotrophic  lateral  sclerosis  begins  with  sj'mptoms  of  lateral 
sclerosis  :  Aveakuess  ;  a  stiff,  awkward,  spastic  gait ;  muscular 
spasm  ;  exaggerated  reflexes  ;  spinal  epilepsy  ;  to  which  in 
turn  may  be  superadded  the  symptoms  of  degeneration  of  the 
anterior  horns  of  the  gray  matter  :  muscular  wasting,  paralysis, 
loss  of  reflexes,  reaction  of  degeneration. 

What  are  the  symptoms  of  progressive  muscular  atrophy  ? 

Progressire  muscular  atrophy  is  usually  insidious  in  onset ;  some- 
times slow,  sometimes  rapid,  but  always  progressive  in  course. 
Muscular  wasting,  preceded  by  pain,  is  first  observed  in  one  por- 
tion of  the  bod}',  usually  in  an  upper  extremity,  and  followed 
by  weakness  ;  both  wasting  and  weakness  in  turn  successively 
invade  all  four  extremities  and  the  trunk  as  well ;  respiration 
may  be  embarrassed.  If  the  duration  of  the  case  be  long  enough, 
symptoms  of  bulbar  paralysis  are  superadded. 

The  wasting  is  especially  manifest  in  the  thenar  and  hypo- 
thenar  eminences  and  in  the  interosseous  spaces  ;  as  a  result,  a 
peculiar  deformity— the  claw-like  hand — develops.  The  wasting 
muscles  are  the  seat  of  spontaneous  fibrillary  contractions.  Me- 
chanical muscular  irritability  is  heightened.  The  deep  reflexes 
are  enfeebled  in  a  degree  proportional  to  the  muscular  wasting. 
The  electric  reactions  are  also  dependent  upon  the  nutrition  of 
the  muscles  and  nerves.  At  first,  they  present  quantitative, 
subsequently  qualitative  changes. 

What  are  the  symptoms  of  chronic  or  progressive  bulbar 
paralysis— glosso-labio-laryngeal  palsy  ? 

The  symptoms  of  glosso-lahio-laryageal  paralysis  are  analogous 
to  those  of  progressive  muscular  atrophy,  the  degenerative  pro- 
cess, however,  involving  the  nuclei  of  the  cerebral  rather  than 
those  of  the  spinal  nerves,  especially  the  facial,  glosso-pharyn- 
geal,  pneumogastric,  spinal  accessory  and  hypoglossal.  The 
disease  is  marked  by  difficulty  in  mastication,  in  deglutition,  in 
respiration,  in  phouatlon  and  articulation,  and  by  wasting  of  the 
21 


322 


ESSENTIALS    OF    D  T  A  (J  N  0  S  I  S , 


muscles  concerned  in  these  functions.    The  affected  muscles  dis- 
play spontaneous  fibrillary  contractions.     Speech  becomes  pro- 

FiG.  45. 


Progressive  Muscular  Atrophy.     (Gowers.) 

1.  Wasting  of  the  muscles  of  the  back  and  arms, 

2.  Wasting  of  the  trapezii  and  deltoids. 

3.  Wasting  of  the  muscles  of  the  neck ;  a,  habitual  posture  of  the  head ;  B,  posi- 
tion into  which  the  head  falls  if  it  be  not  inclined  backward. 

gressively  more  difficult,  indistinct,  and  finally  nasal.    Swallow- 
ing is  difficult  and  fluids  regurgitate  through  the  nose.    Saliva 


ACUTE  BULBAR  PALSY.  323 

clribl)les  from  the  mouth.  Food  may  find  its  way  into  the  larynx. 
Keflex  action  in  the  throat  may  be  lost.  Earely  the  ocular  and 
the  facial  muscles  participate  in  the  palsy. 

How  is  progressive  muscular  atrophy  to  be  distinguished  from 
acute  anterior  poliomyelitis  ? 

Progressive  muscular  atrophy  is  especially  a  disease  of  adult 
life.  It  is  usually  gradual  in  onset  and  progressive  in  course, 
while  acute  anterior  poliomyelitis  is  especially  a  disease  of  child- 
hood, and  is  acute  in  onset  and  retrogressive  in  course.  Febrile 
symptoms  attend  acute  poliomyelitis,  but  not  progressive  atro- 
phy. The  fibrillary  twitching  of  the  latter  is  not  present  in  the 
former.  Terminal  bulbar  symptoms  attend  progressive  muscu- 
lar atrophy,  but  not  acute  poliomyelitis. 

How  are  progressive  muscular  atrophy  and  progressive  neu- 
ral muscular  atrophy  to  be  diiferentiated  ? 

The  condition  that  has  been  described  as  the  peroneal  type 
of  progressive  muscular  atrophy  is  dependent  upon  neuritis 
and,  in  addition  to  weakness,  wasting,  degenerative  electric 
reactions  and  deformities,  presents  sensory  disturbances.  Be- 
sides, it  usually  sets  in  early  in  life  and  attacks  first  the  feet 
and  the  legs,  sometimes  the  hands  and  the  forearms,  gradually 
extending.  Several  members  of  the  same  family  are  sometimes 
attacked. 

Acute  Bulbar  Palsy. 

What  is  acute  bulbar  palsy  ? 

Symptoms  almost  identical  with  those  of  progressive  glosso- 
labio-laryngeal  paralysis  may  set  in  acutely.  They  may  subse- 
quently undergo  some  improvement  and  then  remain  stationary. 
The  condition  is  dependent  upon  an  acute  lesion— softening  or 
hemorrhage  or  inflammation  of  the  medulla,  involving  the  nuclei 
of  the  glosso-pharyngeal,  pneumogastric,  spinal  accessory  and 
hypoglossal  nerves  or  the  fibers  passing  to  or  from  them. 

How  is  acute  to  be  distinguished  from  chronic  bulbar  palsy  ? 

The  symptoms  of  chronic  bulbar  palsy  are  gradual  in  onset, 
progressive  in  course   and  symmetrical  in  distribution  ;  those 


324  ESSENTIALS   OP   DIAGNOSIS. 

of  acute  bulbar  palsy  are  sudden  in  onset,  regressive  or  sta- 
tionary and  arc  apt  to  display  slight  irregularities  of  distribu- 
tion. 

Pseudo-Bulbar  Palsy. 

What  is  pseudo-bulbar  palsy? 

A  bilateral  lesion,  such  as  softening  or  hemorrhage,  involving 
the  lower  portion  of  the  ascending  frontal  convolution  of  both 
hemispheres,  or  the  corresponding  motor  tracts  in  symmetrical 
situations,  vidll  give  rise  to  the  symptoms  of  bulbar  palsy  :  para- 
lysis of  the  lips,  tongue  and  throat. 

How  is  pseudo-bulbar  palsy  to  be  distinguished  from  true  bul- 
bar palsy  ? 

Pseudo-bulbar  palsy,  in  contradistinction  to  true  bulbar 
palsy,  is  likely  to  be  characterized  by  two  distinct  attacks,  by 
slight  asymmetry  of  distribution  of  the  symptoms,  and  by  the 
absence  of  wasting. 

Asthenic  Bulbar  Paralysis. 

What  is  asthenic  bulbar  paralysis  ? 

Asthenic  bulbar  paralysis  is  a  disorder  of  unknown,  though 
possibly  toxic  origin,  characterized  by  weakness  of  voluntary 
muscles,  and  especially  those  controlled  by  the  bulbar  nerves, 
or  by  undue  readiness  of  fatigue  after  ordinary  functional 
activity,  without  wasting  or  changes  in  reflexes  or  in  sensibility. 
Remissions  and  exacerbations  are  common  and  often  abrupt. 
The  affected  muscles  are  readily  exhausted  by  tetanizing  electric 
currents. 

Progressive  Muscular  Dystrophy. 

What  are  the  symptoms  of  progressive  muscular  dystrophy  ? 

Progressive  muscular  dystrophy  is  a  congenital  or  family-aflec- 
tion,  transmitted  through  females,  but  occurring  more  commonly 
in  males,  usually  appearing  in  childhood,  and  characterized  by 
weakness  and  wasting  of  muscles,  the  fibers  of  which  may  first 
undergo  hypertrophy  and  then  atrophy,  while  the  interstitial 
and  fatty  tissue  increases.   Several  varieties  have  been  described 


PROGRESSIVE  MUSCULAR  DYSTROPHY. 


325 


— idiopathic,  pseudo-hypertrophic,  juvenile  or  scapido-humeral,  in- 
fantile or  facio-scapulo-humeral,  hereditary — in   accordance  with 


Fig.  46. 


Progressive  muscular  dystrophy  of  pseudo-hypertrophic  type  in   two  brothers. 

(Gowers.) 

tlie  distribution,  the  time  of  appearance  and  the  presence  or 
absence  of  primary  enlargement. 

The  disease  usually  makes  its  appearance  early  in  life  and  is 
progressive  in  course. 

The  gait  has  a  peculiar  oscillating  character  ;  ascending 
stairs  is  difficult,  and  the  manner  of  rising  from  the  floor  is 
characteristic  (Fig.  47)  :  the  patient  first  gets  on  his  hands  and 
knees  ;  then  extending  the  legs  he  stands  upon  liis  feet ;  finally, 
by  supporting  his  hands  upon  his  thighs  he  manages  to  reach 
the  erect  posture.  Ultimately  the  muscles  become  reduced  in 
size  ;  the  electric  reactions  suffer  quantitative   changes,  indica- 


326  ESSENTIALS    OF    DIAGNOSIS, 

Fig.  47. 


Progressive  muscular  dystrophy.    Mode  of  rising  from  the  ground.    (Gowers.) 

tive  of  diminished  excitability ;  the  deep  reflexes  are  enfeebled 
and  lost.  Talipes  equinus,  spinal  curvature  and  muscular  con- 
tractions occur  at  a  late  stage  of  the  disease.  Intelligence  does 
not  suffer,  and  sensibility  and  the  function  of  the  sphincters 
remain  unimpaired. 


Arthritic  Muscular  Atrophy. 

What  is  arthritic  muscular  atrophy 

It  has  been  observed  that  in  the  course  of  inflammation  of  a 
joint,  acute  or  chronic,  spontaneous  or  traumatic,  the  related 
muscles,  especially  the  extensors,  undergo  a  varying  degree  of 
atrophy.  With  the  disappearance  of  the  arthritis,  the  afiected 
muscles  gradually  return  to  their  normal  condition.  If  the 
joint-disorder  continue  for  a  long  period,  the  deep  reflexes  in 
the  region  involved  are  heightened  and  the  muscles  present 
quantitative  electrical  changes  ;  contracture  of  the  opponent 
muscles  may  also  occur. 


THOMSEN's    disease LOCOMOTOR    ATAXIA.     327 

Thomsen's  Disease — Myotonia  Congenita. 

What  are  the  symptoms  of  myotonia  congenita— Thomsen's 
disease  ? 
The  disorder  described  hy  Thomsen  is  one  that  occurs  as  a 
congenital  aftection  in  families.  It  is  characterized  by  tonic 
muscular  spasm  on  voluntary  movement  following  a  period  of 
rest.  If  movement  is  persevered  in,  the  spasm  relaxes.  The 
spasm  is  intensified  by  emotion  or  by  the  fear  of  its  occurrence. 
Muscular  hypertrophy  is  the  ultimate  result.  A  peculiar  elec- 
tric reaction,  myotonia  electrica,  is  developed,  the  muscular  con- 
tractions induced  attaining  their  maximum  slowly  and  subse- 
quently relaxing  slowly. 

Posterior  Spinal  Sclerosis — Locomotor  Ataxia. 

What  are  the  causes  of  posterior  spinal  sclerosis  ? 

Posteri/yr  spinal  sclerosis,  locomotor  ataxia.^  or  tabes  dorsdlis  is 
more  common  in  males  than  in  females,  and  in  middle  adult  life 
than  at  any  other  period.  Its  most  common  cause  is  syphilis  ; 
other  causes  are  exposure  to  cold  and  wet,  concussion,  over- 
exertion and  sexual  and  alcoholic  excesses  ;  the  disease  has 
been  observed  to  follow  acute  infectious  diseases ;  it  is  some- 
times secondary  to  other  forms  of  spinal  disease  ;  in  some  cases 
an  hereditary  neurotic  influence  can  be  traced.  It  has  been 
attributed  to  metallic  poisoning.  The  etiology  is  sometimes 
obscure. 

What  are  the  symptoms  of  posterior  spinal  sclerosis  ? 

Posterior  spinal  sclerosis  is  characterized  by  impairment  of 
coordination,  giving  rise  to  difficulty  in  performing  delicate 
movements,  to  unsteadiness  of  gait  and  of  station,  particularl}' 
when  the  guidance  of  vision  is  removed  ;  by  shooting  pains  in 
the  extremities  ;  by  a  girdle-sensation  ;  by  other  abnormalities 
of  sensation,  particularly  anesthesia,  and  especially  in  the  soles 
of  the  feet ;  by  abolition  of  the  deep  reflexes  ;  by  primary  ex- 
aggeration and  secondary  loss  of  the  superficial  reflexes ;  by 
primary  increase  of  the  sexual  propensity  and  secondary  impair- 
ment of  the  sexual  power  ;  by  derangement  of  the  sphincters, 
manifested  by  retention  or  incontinence  ;  by  narrow  pupils  that 


328  ESSENTIALS    OF   DIAGNOSIS. 

act  in  accommodation,  but  do  not  respond  to  the  stimulus  of 
light ;  by  paralysis  of  ocular  muscles,  giving  rise  to  strabismus 
and  diplopia  ;  by  atrophy  of  the  optic  and  auditory  nerves,  occa- 
sioning loss  of  vision  and  of  hearing  ;  by  laryngeal,  gastric,  in- 
testinal and  other  visceral  crises,  manifested  by  paroxysms  of 
intense  distress  ;  by  trophic  changes  in  the  joints,  giving  rise  to 
enlargement  and  subluxation,  rendering  the  bones  brittle  and 
liable  to  spontaneous  fracture  ;  by  perforating  ulcers  of  the 
foot;  sometimes  by  peripheral  neuritis;  by  hyperextensibility 
at  the  joints,  particularly  the  knee  and  the  hip ;  and  in  the  last 
stages  by  muscular  wasting. 

How  is  multiple  neuritis  to  be  distinguished  from  posterior 
spinal  sclerosis  ? 
If  abolition  of  the  reflexes,  unsteady  gait  and  station,  loss  of 
sensation  and  sharp  pains  attend  neuritis,  they  maj'  recede  and 
ultimatel}^  disappear  ;  once  present  in  the  course  of  posterior 
spinal  sclerosis  they  persist.  Posterior  sclerosis  is  progressive 
in  course,  and  unyielding  in  treatment.  With  appropriate 
treatment  neuritis  is  retrogressive.  The  sjirdle-sensation  of 
sclerosis  is  wanting  in  neuritis.  In  neuritis,  the  muscles 
undergo  degeneration  and  waste  ;  there  is  palsy  ;  the  electric 
reactions  are  qualitatively  changed.  In  sclerosis,  muscular 
wasting  and  weakness  result  only  after  long-continued  inactivity  ; 
if  the  electric  reactions  undergo  any  change,  it  is  quantitative. 
In  neuritis  there  are  pains  and  points  of  special  tenderness  in 
the  course  and  in  the  peripheral  distribution  of  various  nerves  ; 
in  posterior  sclerosis  the  muscles  are  not  tender.  In  walking 
the  foot  is  raised  high  in  posterior  sclerosis  and  brought  down 
on  the  heel  or  the  sole ;  in  neuritis  foot-drop  necessitates  rais- 
ing the  foot  only  so  high  as  to  avoid  scraping  the  floor. 

How  are  lumbar  pachymeningitis  and  posterior  spinal  sclerosis 
to  be  differentiated  ? 

Pachymeningitis  in  tlie  lumbar  region  may  be  attended  with 
shooting  pains  in  the  thighs  and  with  abolition  of  the  knee- 
jerks,  but  not  with  manifestations  indicative  of  involvement  of 
cerebral  nerves.  In  meningitis  the  muscles  waste  early  ;  in 
posterior  sclerosis,  not  at  all  or  only  late.  Impairment  of  co- 
ordination characterizes  posterior  sclerosis. 


PRIMARY    LATERAL    SCLEROSIS.  329 

What  are  the  distinctions  between  posterior  spinal  sclerosis 
and  cerebellar  tumor? 

A  tumor  in  or  compressing  the  middle  lobe  of  the  cerebellum 
may  give  rise  to  unstable  equilibrium  and  to  a  staggering  gait; 
it  gives  rise  in  addition  to  occipital  headache,  to  vertigo,  vomit- 
ing, nystagmus,  optic  neuritis  and  to  other  evidences  of  com- 
pression ;  while  lightning-pains  and  alterations  of  sensation  are 
wanting. 

Primary  Lateral  Sclerosis — Spastic  Paraplegia. 

What  are  the  causes  of  primary  lateral  sclerosis  ? 

Primary  lateral  sclerosis  or  sjMstic  paraplegia  occurs  with  equal 
frequency  in  both  sexes,  and  a  little  earlier  in  life  than  posterior 
sclerosis. 

In  many  cases,  no  etiologic  element  can  be  discovered  ;  in 
others,  there  is  a  history  of  concussion,  of  exposure  to  cold  and 
wet,  of  syphilis,  of  excesses  or  of  neurotic  heredity. 

What  are  the  symptoms  of  primary  lateral  sclerosis  ? 

Primary  lateral  sclerosis,  or  spastic  paraplegia,  is  character- 
ized by  muscular  weakness  and  spasm  ;  the  latter  usually 
involves  the  extensors  of  the  lower  extremities  occasioning  a 
peculiar  spastic  gait  and  so-called  "  clasp-knife"  rigidity  ;  at- 
tacks of  "  spinal  epilepsy"  occur  ;  the  reflexes  are  exaggerated  ; 
ankle-clonus  is  present.  There  is  usuall}''  muscular  wasting, 
occasionally  hypertrophy.  The  arms  are  affected  less  commonly 
and  in  less  degree  than  the  legs.  There  may  be  abnormal  sen- 
sations, but  no  anesthesia.     The  sphincters  may  be  involved. 

The  electric  reactions  undergo  quantitative  changes. 

How  is  lateral  sclerosis  to  be  distinguished  from  myelitis  ? 

While  lateral  sclerosis  presents  the  symptoms  of  degeneration 
of  the  lateral  columns,  as  seen  in  myelitis,  it  is  always  gradual 
in  onset  and  unattended  with  febrile  manifestations,  with  girdle- 
pain,  or  with  impairment  of  sensation.  Typical  paraplegia, 
with  muscular  wasting  and  degeneration  and  impairment  of  the 
sphincters  is  less  characteristic  of  lateral  sclerosis  than  of 
myelitis. 


330  ESSENTIALS   OP   DIAGNOSIS. 

How  may  lateral  sclerosis  simulate  and  be  distinguished  from 
cerebral  hemiplegia  ? 
The  manifestations  of  primary  lateral  sclerosis  may  be  uni- 
lateral ;  but  the  face  is  not  involved,  as  it  usually  is  in  hemi- 
plegia of  cerebral  origin  ;  and  careful  examination  will  detect 
exaggeration  of  the  reflexes  of  the  upper  as  well  as  of  the  lower 
extremity  on  the  apparently  uninvolved  side,  unlike  what  is 
found  in  cerebral  hemiplegia. 

Postero-lateral  Sclerosis— Ataxic  Paraplegia. 

What  are  the  causes  of  ataxic  paraplegia  or  postero-lateral 
sclerosis  ? 

Postero-lateral  sclerosis,  or  ataxic  paraplegia,  i-s  more  common 
in  males  than  in  females  and  in  middle  adult  life  than  at  any 
other  period.  Its  etiology  is  often  obscure.  In  some  cases  a 
neurotic  heredity  can  be  traced  ;  in  others  there  has  been  ex- 
posure to  cold  and  wet ;  in  still  others  concussion  seems  to  have 
been  the  cause  ;  a  history  of  syphilis  is  uncommon. 

What  are  the  symptoms  of  postero-lateral  sclerosis,  or  ataxic 
paraplegia  ? 

The  symptoms  of  ataxic  paraplegia  are  dependent  upon 
sclerosis  of  the  posterior  and  lateral  columns  of  the  spinal  cord. 
The  disease  is  gradual  in  onset  and  marked  by  muscular  weak- 
ness, spasm  and  incoordination.  There  may  be  pain  in  the 
sacral  regiop,  but  lightning-pains  are  absent.  Articulation  may 
be  defective.  Tremor  of  the  muscles  of  the  face  may  occur.  The 
deep  reflexes  are  exaggerated.  The  iris  usually  reacts  to  light. 
Atrophy  of  the  optic  nerve  is  rare.  Sexual  power  may  be  lost. 
The  sphincters  become  enfeebled.  Ultimately,  contractures 
develop. 

How  is  posterior  spinal  sclerosis  to  be  distinguished  from 
postero-lateral  sclerosis  ? 

POSTERIOR    SCLEROSIS.  POSTERO-LATERAL    SCLEROSIS. 

Syphilis  a  common  cause.  Syphilis  a  rare  cause. 

Weakness  a  late  symptom .  Weakness  an  early  symptom. 

Knee-jerk  lost  early.  Knee-jerk  exaggerated. 


HEREDITARY    ATAXIC    PARAPLEGIA.  331 

POSTERIOR    SCLEROSIS.  POSTERO-LATERAL   SCLEROSIS. 

No  ankle-clonus.  Ankle-clonus. 

Never  muscular  spasm.  Characteristic  muscular  spasm. 

Argyll-Robertson  pupil.  Pupil  responds  to  light. 

Lightning-pains.  Dull  sacral  pains. 

Sensory  impairment.  Sensation  unimpaired. 

Girdle-sensation.  No  girdle-sensation. 

Optic-nerve  atrophy  common.  Optic-nerve  atrophy  rare. 

Visceral  crises.  No  crises. 

How  is   postero-lateral   sclerosis   to   be   distinguished  from 
primary  lateral  sclerosis? 

Ataxic  paraplegia  is  to  be  distinguished  from  spastic  para- 
plegia by  the  presence  of  symptoms  of  muscular  incoordination, 
dependent  upon  involvement  of  the  posterior  columns  of  the 
cord. 

What  are  the  distinctions  between  a  tumor  of  the  cerebellum 
and  postero-lateral  sclerosis  ? 
A  trrowth  involving  the  middle  lobe  of  the  cerebellum  may 
give  rise  to  weakness,  ataxia,  spasm,  and  heightened  reflexes  ; 
there  are,  besides,  occipital  headache,  optic  neuritis,  vertigo, 
vomiting  and  nystagmus  ;  other  evidences  of  pressure  may  be 
present. 

-Friedreich's  Ataxia— Hereditary  Ataxic 
Paraplegia. 

What  are  the  symptoms  of  Friedreich's  ataxia? 

The  symptoms  of  FriedreidVs  ataxia  are  dependent  upon 
sclerosis  of  the  lateral  and  posterior  columns  of  the  spinal  cord. 
The  disease  occurs  in  families  and  appears  early  in  hfe  ;  it 
attacks  both  sexes  alike.  It  is  attended  with  an  ataxic  gait, 
impairment  of  coordination  and  equilibration,  muscular  weak- 
ness, aboUtion  of  knee-jerks,  early  talipes  equinus,  lateral  curva- 
ture of  the  spine,  nystagmus  and  defective  speech ;  sensation  is 
usually  unimpaired. 

What  are  the  distinctions  between  Friedreich's  ataxia  and 
ataxic  paraplegia? 

The  early  period  of  life  at  which  the  symptoms  appear,  its 
occurrence  in  families,  the  absence  of  knee-jerks  and  of  ankle- 


332  ESSENTIALS    OF   DIAGNOSIS. 

clonus  and  the  presence  of  nystagmus  distinguish  Friedreich's 
disease  from  ataxic  paraplegia. 

Cerebro-Spinal  Sclerosis— Insular  Sclerosis. 

What  are  the  causes  of  cerebro-spinal  sclerosis? 

The  more  commonly-recognized  causes  of  disseminated^  mul- 
tiple, insular,  or  cerebro-spinal  sclerosis  are  exposure  to  cold  and 
wet,  traumatism,  nervous  shock  and  acute  febrile  diseases.  Oc- 
casionally a  neuropathic  heredity  can  be  traced. 

What  are  the  symptoms  of  cerebro-spinal  sclerosis  ? 

The  symptoms  of  disseminated,  multiple,  insular,  or  cerebro- 
spinal sclerosis  vary  with  the  distribution  of  the  islets  of  sclerosis. 
As  a  rule,  there  is  a  peculiar  jerky  incoordination  or  tremor,  most 
marked  in  the  upper  extremities,  and  sometimes  involving  the 
head  and  the  tongue,  aggravated  by  eifort,  emotion  or  observa- 
tion ;  there  is  commonly  nystagmus,  usually  lateral,  sometimes 
vertical,  sometimes  rotatory  ;  speech  is  often  slow,  scanning, 
syllabic,  parts  of  words  being  dropped  ;  the  reflexes  are  usually 
exaggerated.  In  addition  there  are  certain  mental  changes, 
often  manifested  by  a  sense  of  complacency,  contentment  and 
self-satisfaction,  quite  at  variance  with  the  patient's  condition. 
Evidences  of  muscular  weakness  are  not  rarely  present.  There 
may  also  be  headache,  vertigo  and  optic  neuritis. 

How  is  cerebro-spinal  sclerosis  to  be  distinguished  from  postero- 
lateral sclerosis  ? 
There  may  sometimes  be  considerable  difficulty  in  differentia- 
ting cerebro-spinal  sclerosis  and  postero-lateral  sclerosis  (ataxic 
paraplegia)  and  Friederich's  (hereditary)  ataxia.  In  postero- 
lateral sclerosis,  the  defect  of  coordination  involves  the  lower 
extremities  primarily ;  in  multiple  sclerosis,  there  is  coarse 
tremor  rather  than  true  incoordination,  and  the  upper  extremi- 
ties are  especially  involved.  Nystagmus  occurs  in  Friedreich's 
ataxia  and  in  multiple  sclerosis,  but  not  in  ataxic  paraplegia. 
The  knee-jerks  are  exaggerated  in  multiple  sclerosis  and  in  ataxic 
paraplegia,  but  are  wanting  in  Friedreich's  ataxia.  Friedreich's 
ataxia  is  a  family-disease  and  appears  early  in  life.     Multiple 


PARALYSIS   AGITANS  —  SHAKING   PALSY.         333 

sclerosis  and  ataxic  paraplegia  appear  in  middle  life.  Cerebral 
symptoms  and  mental  phenomena  belong  to  multiple  sclerosis 
rather  than  to  postero-lateral  sclerosis.  Speech  is  slow  and 
scanning  in  cerebro-spinal  sclerosis  ;  in  Friedreich's  ataxia 
there  are  merely  elision  and  occasional  separation  of  syllables. 

Paralysis  Agitans— Shaking  Palsy. 

What  conditions  favor  the  development  of  paralysis  agitans  ? 

Pai'alysis  agitans  or  shaking  palsy  begins  most  commonly  at 
about  fifty  years  of  age.  It  is  more  common  in  males  than  in 
females.  In  some  cases,  an  hereditary  influence  can  be  traced 
in  an  etiologic  connection.  In  others,  the  onset  of  the  disease 
has  been  preceded  by  decided  emotional  disturbance,  by  phys- 
ical injury  or  by  acute  disease. 

What  are  the  symptoms  of  paralysis  agitans  ? 

Paralysis  agitans,  shaking  palsy  or  Par'kinscm''s  disease  is  char- 
acterized by  tremor,  weakness  and  rigidity.  Tremor  is  usually 
first  observed  ;  weakness  and  rigidity  subsequently.  The  mani- 
festations first  appear  in  one  extremity,  and  gradually  extend 
to  the  others.  The  tremor  is  fine  and  rhythmic ;  it  is  in- 
creased by  observation  and  by  emotional  disturbance,  and 
diminished  or  restrained  temporarily  by  active  and  by  passive 
movement,  and  sometimes  spontaneously.  As  a  rule,  the  head 
does  not  participate  in  the  tremor ;  exceptionally  it  does.  The 
expression  of  the  face  is  fixed  and  immobile.  The  shoulders 
are  bent  forward,  giving  rise  to  the  phenomena  of  propulsion — 
a  tendency  to  run  forward.  Occasionally  there  is  retropulsion, 
or  there  may  be  a  tendency  to  lateral  movement.  The  hands 
assume  a  peculiar,  semi-flexed  attitude,  the  fingers  performing 
movements  as  if  rolling  a  small  object  between  their  tips;  or 
the  fingers  are  held  as  if  grasping  a  pen.  The  voice  is  mo- 
notonous ;  words  are  uttered  rapidly,  with  a  tendency  to  con- 
fluence of  S3'llables.  The  reflexes  are  usuall}^  unaltered  ;  ex- 
ceptionally the  knee-jerks  are  exaggerated  and  ankle-clonus 
can  be  elicited.  A  sensation  of  abnormal  heat,  sometimes  with 
perspiration,  is  often  present. 


334 


ESSENTIALS    OF    DIAGNOSIS 


What  are  the  differential  features  between  paralysis  agitans 

and  cerebro-spinal  sclerosis  ? 

The  diagnosis  between  these  two  conditions,  ordinarily  simple, 

may  under  some  circumstances  be  extremely  ditRcult.      The 

tremor  of  cerebro-spinal  sclerosis  is  coarse  and  irregular,  and  is 

■      Fig.  48. 


Paralysis  agitans.    (After  St.  Leger.) 


induced  and  aggravated  by  voluntary  eflbrt,  by  emotion  and  by 
observation  ;  that  of  paralysis  agitans  is  fine  and  regular,  and 
is  constant,  at  least  during  the  waking  hours.  In  cerebro-spinal 
sclerosis,  the  head  participates  in  the  movements  ;  in  paralysis 
agitans,  on  the  contrary,  the  face  is  fixed,  immobile,  expression- 
less. Paralysis  agitans  does  not  present  the  slow,  scanning 
speech  and  nystagmus  of  multiple  sclerosis  ;  while  the  latter  does 
not  present  the  tendency  to  forward  or  backward  or  even  lateral 
movement  of  the  former.  The  characteristic  attitude  of  the 
hand,  as  if  holding  a  pen  in  writing,  or  as  if  rolling  pills  between 
the  fingers,  seen  in  paralysis  agitans,  is  not  seen  in  multiple  scle- 
rosis. 


SriNAL   HEMORRHAGE.  335 

Spinal  Hemorrhage. 

What  are  the  causes  of  hemorrhage  into  the  spinal  cord? 

Spinal  hemorrhage  is  more  common  in  males  than  in  females, 
and  in  adult  life  than  at  any  other  period.  It  may  be  primary, 
dependent  upon  disease  of  the  bloodvessels,  or  as  a  result  of 
exposure  to  cold,  or  of  over-exertion,  or  of  sexual  excess  ;  second- 
ary, in  the  course  of  inflammation,  tumors  and  cavities  in  the 
cord  ;  accessory,  occurring  towards  the  close  of  convulsive  dis- 
orders ;  and  traumatic,  following  blows,  falls  and  other  injuries. 

What  are  the  symptoms  of  hemorrhage  into  the  spinal  cord? 

The  occurrence  of  hemorrhage  into  the  spinal  cord  is  indicated 
by  sudden,  severe  pain  in  the  back,  with  loss  of  motion  and 
sensation.  Consciousness  may  be  lost,  but  is  likely  to  be  pre- 
served. A  girdle-sensation  exists  at  the  level  of  the  lesion,  and 
loss  of  motion  and  sensation  below,  on  alternate  sides,  or  on 
both  sides  of  the  body,  according  to  the  seat  of  the  lesion.  The 
sphincters  are  likely  to  be  deranged  and  trophic  changes  to 
occur.  Respiration  will  be  interfered  with  if  the  lesion  is  in  the 
cervical  or  dorsal  region  of  the  cord. 

Some  degree  of  myelitis  and  meningitis  are  usually  developed 
in  the  progress  of  the  case,  giving  rise  to  fever  and  irritative 
symptoms.  Subsequently,  the  symptoms  become  paralytic  in 
type.  Some  degree  of  paraplegia  remains  permanently.  The 
paralyzed  muscles  waste.     The  deep  reflexes  are  exaggerated. 

What  are  the  distinctions  between  spinal  hemorrhage  and 
spinal  meningitis  ? 

The  abruptness  of  onset  is  more  decided  in  hemorrhage  than 
in  meningitis.  Febrile  manifestations  attend  meningitis  from 
the  beginning  ;  they  only  appear  in  hemorrhage  when  mj'elitis 
is  established.  Motor  and  sensory  impairment  is  more  decided 
in  hemorrhage  than  in  meningitis  ;  in  the  latter,  there  is  a 
preliminary  stage  of  spasm  and  pain. 

How  are  hemorrhage  into  the  cord  and  hemorrhage  into  the 
meninges  to  he  distinguished  from  one  another  ? 
Both  the  local  and  the   radiating  pains  are  less  severe  in 
spinal  than  in  meningeal  hemorrhage,  w^hile   the  subsequent 


336  ESSENTIALS    OF    DIAGNOSIS. 

anesthesia  is  more  decided  in  the  former  than  in  the  latter. 
In  the  case  of  spinal  hemorrhage  the  paralytic  symptoms  are 
more  decided  from  the  outset ;  while  in  meningeal  hemorrhage 
these  are  preceded  by  muscular  spasm.  Trophic  changes  char- 
acterize spinal  hemorrhage,  and  are  wanting  in  meningeal 
hemorrhage. 

Spinal  Compression. 

What  are  the  causes  of  compression  of  the  spinal  cord? 

The  cord  may  be  compressed  by  tumors  of  the  spinal  canal ; 
by  dislocation  of  the  vertebrae,  independently,  or  as  a  result  of 
caries,  or  of  fracture  ;  by  an  exostosis  ;  by  an  aneurism  that  has 
eroded  the  bones  ;  or  by  an  hydatid  cyst. 

How  can  the  causes  of  spinal  compression  be  differentiated? 

The  recognition  of  a  tumor  in  the  spinal  canal  depends  upon 
its  detection  from  without,  or  the  detection  of  new-growths  in 
other  parts  of  the  body. 

Simple  dislocation  and  fracture  of  the  vertebrae  follow  trau- 
matism ;  the  symptoms  to  which  dislocation  gives  rise  set  in 
suddenly  and  are  profound  in  degree  ;  a  deformity  of  the  spinal 
column  may  be  detectable. 

The  diagnosis  of  caries  depends  upon  the  knowledge  of  a 
history  of  syphilis  or  of  tuberculosis  and  the  detection  of  a 
painful  deformity  in  the  back. 

An  hydatid  cyst  of  the  spinal  canal  may  be  diagnosticated  by 
the  detection  externally  of  a  fluctuating  tumor,  upon  puncture 
of  which  the  characteristic  booklets  may  be  found. 

It  may  be  impossible  to  diagnosticate  the  cause  of  compres- 
sion of  the  cord  dependent  upon  an  exostosis  or  upon  an  aneu- 
rism. 

To  what  symptoms  does  compression  of  the  spinal  cord  give 
rise? 
The  rapidity  with  which  the  symptoms  of  compression  appear 
depends  somewhat  upon  the  cause.  Dislocation  is  apt  to  occa* 
sion  manifestations  of  immediate  gravity.  In  other  cases,  the 
symptoms  are  gradual  in  appearance  and  progressive  in  course. 


TUMOR    OF    THE    SPINAL    CORD.  337 

Compression  gives  rise  to  two  groups  of  phenomena,  referable 
to  tlie  nerve-roots  and  to  the  cord,  respectively.  There  is  local 
pain  in  the  back,  aggravated  by  movement,  as  well  as  pains  of 
a  radiating  character,  with  girdle-sensation  ;  ultimately  anes- 
thesia develops.  There  is  loss  of  motion  in  the  parts  supplied 
by  the  nerves  from  the  cord  below  the  seat  of  compression  ; 
with  exaggerated  reflexes,  and  involvement  of  the  sphincters. 
The  palsied  muscles  slowly  waste  and  degenerative  reactions 
set  in.     Contractures  may  develop. 

How  is  compression-myelitis  to  be  distinguished  from  hemor- 
rhage into  the  spinal  cord  ? 

When  a  vertebra  softened  by  destructive  disease  suddenly 
gives  way,  the  resulting  displacement  may  be  followed  by  com- 
pression of  the  cord,  occasioning  symptoms  with  which  those 
produced  by  hemorrhage  into  the  cord  may  be  identical.  The 
symptoms  of  compression,  however,  are  usuall}'  more  extensive 
and  more  absolute  than  those  of  hemorrhage  ;  the  existence  of 
a  deformity  of  the  spine  makes  the  diagnosis  certain. 

What  are  the  distinctions  between  compression  of  the  cord  and 
chronic  myelitis  ? 

Symptoms  of  irritation  referable  to  the  nerve-roots  are  want- 
ing in  myelitis.  The  recognition  of  a  cause  of  compression 
determines  the  diagnosis. 

Tumor  of  the  Spinal  Cord. 

What  are  the  symptoms  of  tumor  of  the  spinal  cord  ? 

Tumors  of  the  spinal  canal  may  be  situated  without  or  within 
the  dura  mater,  or  within  the  structure  of  the  cord  itself.  They 
are  most  diverse  in  character.  The  symptoms  will  depend  upon 
the  situation  of  the  tumor  and  upon  the  degree  of  mechanical 
interference  with  the  functions  of  the  cord  that  it  occasions. 
Pressure  on  the  nerve-roots  gives  rise  to  pain,  to  abnormal  sen- 
sations, to  girdle-pain  and  to  muscular  spasm  and  rigidity. 
Pressure  on  the  cord  or  myelitis  occasions  anesthesia,  paral3^sis 
and   exaggerated   reflexes  below  the  level    of  the  lesion  and 

22 


338  ESSENTIALS    OF   DIAGNOSIS. 

abolition  of  the  reflexes  within  the  area  innervated  from  the 
seat  of  the  growth.  Involvement  of  the  anterior  horns  of  the 
gray  matter  is  attended  with  wasting  and  other  trophic  dis- 
orders ;  involvement  of  the  lumbar  enlargement  causes  abolition 
of  the  knee-jerk,  loss  of  control  of  the  sphincters  and  wasting 
and  palsy  in  the  lower  extremities  ;  involvement  of  the  cervical 
enlargement  occasions  wasting  and  palsy  in  the  upper  ex- 
tremities. The  unilateral  appearance  of  symptoms  of  spinal 
disease,  or  evidence  of  sensory  derangement  on  one  side  and 
motor  derangement  on  the  other,  is  strongly  suggestive  of 
tumor  of  the  spinal  canal.  With  the  growth  of  the  tumor  the 
symptoms  become  bilateral. 

From  what  conditions  is  spinal  tumor  to  be  distinguished? 

The  diagnosis  of  spinal  tumor  includes  the  determination  of 
the  nature  of  the  tumor  and  its  distinction  from  other  condi- 
tions presenting  similar  symptoms. 

In  the  first  connection,  a  history  of  syphilis,  of  tuberculosis, 
or  of  tumors  situated  elsewhere  is  to  be  considered. 

The  differentiation  from  caries  of  the  vertebrse  depends  upon 
the  recognition  of  disease  of  the  bone,  upon  the  deformity  that 
results  and  upon  the  greater  degree  of  pain  on  movement  that 
attends  caries. 

From  hypertrophic  pachymeningitis  spinal  tumor  differs  in 
course;  being  more  rapidly  progressive,  while  symptoms  of 
irritation  precede  those  of  paralysis  and  Avasting.  The  symp- 
toms of  pachymeningitis  are  bilateral  from  the  outset  and  more 
circumscribed  in  distribution  than  are  those  of  tumor. 

The  symptoms  of  tumor  differ  from  those  of  myelitis,  in  be- 
ing irritative  in  character— attended  by  pain  and  spasm,  rather 
than  paralytic.  If  tumor  give  rise  to  myelitis,  the  recognition 
of  the  condition  depends  upon  a  knowledge  of  the  previous 
symptoms. 

The  persistence  of  obstinate  neuralgia,  especially  if  bilateral, 
should  excite  suspicion  of  spinal  tumor. 


SYRINGOMYELIA.  339 

Syringomyelia. 

What  are  the  symptoms  of  syringomyelia  ? 

Cavities  in  the  spinal  cord  may  be  a  result  of  defective  appo- 
sition of  the  lateral  halves  of  the  cord  in  the  course  of  devel- 
opment ;  of  occlusion  of  the  central  canal,  with  accumulative 
distention  by  cerebro-spinal  fluid  ;  of  the  disintegration  of 
gliomata  ;  or  they  may  appear  subsequently  to  myelitis.  The 
course  of  the  disease  is  slow  and  chronic,  sometimes  covering 
many  years.  The  symptoms  vary  somewhat  with  the  situation 
of  the  cavity.  They  are  usually  most  conspicuous  in  the  upper 
extremities.  They  may  be  largely  bulbar.  There  are  muscular 
wasting  and  weakness,  preceded  by  alterations  of  sensation. 
Common  sensibility  is  usually  preserved,  while  the  perception 
of  pain  and  of  heat  and  cold  is  enfeebled  or  lost.  In  some  cases 
severe  pains  occur.  A  spastic  condition  may  be  present  in  the 
lower  extremities.  Tlie  sphincters  may  escape  or  be  involved. 
Trophic  changes  are  comm^on,  and  arthropathies  are  occasion- 
ally observed.  There  may  be  cutaneous  eruptions,  as  eczema 
or  herpes.  The  skin  may  be  thin  and  glossy  or  thick  and  horny. 
Undue  sweating  may  take  place.  Vaso-motor  disturbance  may 
be  manifested  by  coldness  and  lividity. 

From  what  conditions  is  syringomyelia  to  be  differentiated? 

^Myelitis,  hypertrophic  pachymeningitis  and  progressive  mus- 
cular atrophy  occasion  certain  symptoms  in  common  with 
syringomyelia. 

Myelitis  is  recognized  by  the  much  more  profound  palsy  and 
loss  of  sensory  power,  without  involvement  of  the  pain-sense 
and  the  temperature-sense  ;  hypertrophic  pachymeningitis  bj^ 
the  attendant  pain  and  the  less  extensive  anesthesia  ;  and 
chronic  muscular  atrophy  by  the  absence  of  conspicuous  sensory 
symptoms. 

How  are  syringomyelia  and  leprosy  to  be  differentiated? 

Many  of  the  symptoms  of  lejorosy  are  dependent  upon  jDcriph- 
eral  neuritis,  so  that  nerves  may  be  swollen  and  tender,  and 
all  forms  of  sensibility  suffer  equally.  Spastic  symptoms  are 
w^anting  and  the  sphincters  are  not  deranged.     The  detection 


340  ESSENTIALS    OF   DIAGNOSIS. 

of  lepra-b.acilli  in  the   serum  of  blisters  or  in  the  discharges 
would  remove  any  doubt  in  diagnosis. 

Morvan's  Disease — Analgesic  Panaris. 

What  are  the  symptoms  of  Morvan's  disease? 

Under  the  name  of  3forvan''s  disease  has  been  described  a 
syndrome  of  symptoms,  including  the  development  of  a  pain- 
less inflammation  at  the  extremities  of  the  fingers,  followed  by 
necrotic  sequestration  of  the  phalanges.  At  the  beginning  of 
the  disease,  the  affected  parts  nmay  be  the  seat  of  pain.  Subse- 
quently, analgesia  develops,  together  with  the  destructive  process 
in  the  fingers.  In  most  cases  abnormal  curvature  of  the  spinal 
column  has  been  observed.  After  death,  hyperplasia  of  the 
connective  tissue  of  the  peripheral  nerves  and  in  the  posterior 
horns,  posterior  cohunns,  and  the  gray  matter  of  the  cervical 
segment  of  the  spinal  cord  has  been  found.  The  disorder  is 
considered  a  variet}'  of  syringomyelia. 

What  is  the  distinction  between  Morvan's  disease  and  sclero- 
derma ? 

Scleroderma  is  a  morbid  condition  in  which,  as  a  result  of 
inflammatory  changes  in  the  subcutaneous  arteries  of  a  varying 
distribution,  hyperplasia  of  the  connective  tissue  takes  place, 
with  hardness,  swelling  and  fulness,  which  in  turn  is  succeeded 
by  contraction  and  atrophy.  The  condition  may  be  circum- 
scribed or  difluse.  It  is  sometimes  attended  with  pigmentation 
and  sometimes  with  desquamation.  The  etiology  of  the  affec- 
tion is  obscure. 

A  condition  in  which  the  extremities  of  the  fingers  close  to 
the  nails  undergo  discoloration,  followed  by  the  formation  of 
bullae,  with  perhaps  loss  of  the  nails  and  shortening  of  the  fin- 
gers, has  been  described  as  a  variety  of  scleroderma  or  sdero- 
dactyly.  When  nose  and  ears  and  face,  as  well  as  hands  and  feet, 
became  reduced  in  size,  the  name  akromikria  has  been  employed. 
In  scleroderma  there  may  be  anesthesia,  but  there  is  not 
analgesia.  Trophic  changes  may  take  place  in  the  affected 
parts,  but  they  are  not  of  a  necrotic  character.  The  nails  may 
be  lost,  but  there  is  no  exfoliation  of  bone. 


MORVAN    S    DISEASE. 


341 


How  are  Morvan's  disease  and  anesthetic  leprosy  to  be  differ- 
entiated ? 
In  anesthetic  leprosy,  a  destructive  process  may  be  set  up  in 
the  extremities,  attended  sometimes  with  the  loss  of  fingers  or 
toes,  but  the  condition  is  usually  to  be  recognized  by  the  asso- 
ciation of  other  definite  S3'mptoms  of  lepros}',  such  as  patches 
of  anesthesia  and  leprous  nodules  in  various  parts  of  the  body. 

Fig.  49. 


Appearance  of  the  hand  in  Morvan's  Disease.    (After  Charcot.) 

From  what  other  conditions  is  Morvan's  disease  to  be  differ- 
entiated ? 

Raynaud's  disease  is  attended  with  cyanosis  of  the  extremities, 
sometimes  terminating  in  gangrene  ;  but  sensibility  remains 
unimpaired  ;  and  there  are  other  characteristic  symptoms. 

Syphilis  may  occasion  a  destructive  dactylitis.  The  diagno- 
sis will  depend  upon  the  absence  of  sensory  symptoms  and  upon 


342  ESSENTIALS    OP    DIAGNOSIS. 

a  knowledge  or  a  history  of  infection  or  of  other  manifestations. 
I^Tecrosis  of  bone  may  attend  diabetes^  but  sensory  symptoms 
are  wanting,  distinctive  symptoms  are  present  and  examination 
of  the  urine  will  make  clear  the  clinical  association. 

Cerebral  Meningitis. 

What  are  the  varieties  of  inflammation  of  the  membranes 
of  the  brain  ? 

Inflammation  of  the  dura,  pia  or  arachnoid  is  known  as 
■pacliy meningitis^  leptomeningitis  or  arachnitis,  respectively  ;  most 
commonly  the  pia  and  arachnoid  are  involved  together — p/'a- 
araGlinitis  or  leptomeningitis.  Inflammation  of  the  dura  mater 
may  be  attended  with  the  extravasation  of  a  membranous 
hemorrhagic  exuda.te— hemorrhagic  pachymeningitis.  Meningitis 
may  especially  involve  the  convexity  or  the  base ;  it  may  be  acute 
or  chronic,  primary  or  secondary ;  it  may  be  simple,  purulent,  tuber- 
culous, syphilitic. 

What  are  the  causes  of  cerebral  meningitis  ? 

Inflammation  of  the  pia  and  arachnoid  may  be  a  result  of 
traumatism  or  of  contiguous  inflammation  ;  it  may  develop  in 
the  course  of  infectious  disease  or  of  pyemia  ;  it  may  depend 
upon  a  deposit  of  tubercles  in  the  membranes. 

What  are  the  symptoms  of  cerebral  meningitis  ? 

The  symptoms  of  meningitis  vary  somewhat,  as  the  base  or  the 
convexity  of  the  brain  is  involved.  Tuberculous  meningitis  is 
usually  basilar.  Meningitis  dependent  upon  causes  other  than 
tubercles,  usually,  though  not  exclusively,  affects  the  convexity. 
Certain  symptoms  are  common  to  meningitis  in  any  situation. 
In  addition  to  those  of  the  associated  condition,  there  are, 
together  with  febrile  manifestations,  headache,  delirium,  vomit- 
ing, convulsions,  retraction  of  the  head,  derangement  of  the 
sphincters,  palsies,  vaso-motor  and  trophic  disturbances,  in- 
equality of  the  pupils  and  irregularity  of  the  pulse  and  respira- 
tion. When  the  base  is  involved,  there  are  optic  neuritis 
followed  by  atrophy,  irritation  followed  by  paralysis  of  cranial 
nerves  and  more  decided  alteration  of  pulse  and  respiration, 


CEREBRAL    MENINGITIS.  343 

trophic  and  vaso-motor  disturbances  and  retraction  of  tlie  head. 
When  the  inflammation  is  tuberculous,  tubercles  may,  on  oph- 
thalmoscopic examination,  be  detected  in  the  choroid. 

What  are  the  symptoms  of  cerebral  pachymeningitis  ? 

Inflammation  of  the  dura  mater  may  be  a  result  of  trauma- 
tism or  of  adjacent  disease.  In  addition  to  the  symptoms  of 
the  primary  condition,  there  may  be  headache,  delirium,  con- 
vulsions, febrile  manifestations.  A  collection  of  pus  may  occa- 
sion paralysis. 

What  are  the  symptoms  of  hemorrhagic  pachymeningitis  ? 

Hemorrhagic  pachymeningitis  is  more  common  in  males  than  in 
females,  and  late  in  life  than  at  any  other  period.  It  is  usually 
preceded  by  a  history  of  alcoholism,  of  insolation,  of  trauma- 
tism, or  of  insanity  ;  it  may  also  develop  in  the  course  of  blood- 
diseases.  It  is  attended  with  headache,  contracted  pupils,  in- 
tellectual torpor,  apoplectiform  convulsions,  unnatural  drowsi- 
ness and  mental  wandering.  The  condition  is  rather  obscure, 
and  the  symptoms  not  well  defined.  It  is  often  unexpectedly 
found  2)0st  mortem. 

How  is  simple  cerebral  meningitis  to  be  distinguished  from 
tuberculous  meningitis  ? 
Ordinarj"  cerebral  meningitis  sets  in  rather  acutely  ;  tubercu- 
lous meningitis  usualh'  more  insidiously.  The  ordinarj'  form  of 
inflammation  is  associated  with  well-known  causes  :  traumatism, 
adjacent  inflammation,  infectious  diseases  and  pyemia  ;  tuber- 
culous meningitis  is  usually  secondary  to  tuberculous  processes 
in  other  parts  of  the  bod}^  The  symptoms  of  the  former  espe- 
cially indicate  involvement  of  the  convexity  and  freedom  of 
the  base,  while  in  the  latter  the  conditions  are  reversed,  and 
choked  disc  and  paralysis  of  cranial  muscles  are  more  common. 
Tubercles  are  never  found  in  the  choroid  in  ordinary  meningitis. 
Simple  meningitis  is  not  uncommonly  attended  with  recovery  ; 
tuberculous  meningitis  but  rarely. 

How  are  the  cerebral  symptoms  of  acute  general  disease  to  be 

distinguished  from  the  symptoms  of  cerebral  meningitis  ? 

Cerebral  symptoms  may  appear  at  any  time  in  the  course  of 


344  ESSENTIALS    OP    DIAGNOSIS. 

acute  general  diseases,  such  as  scarlatina,  smallpox,  yellow 
fever,  typhoid  fever,  rheumatism,  pneumonia  and  acute  miliary 
tuberculosis.  Investigation  should  be  directed  to  the  deter- 
mination of  the  association,  so  that  the  primary  condition  may 
not  be  obscured.  Sufficient  cause  for  the  symptoms  may  be 
found  in  the  high  temperature,  in  the  state  of  inanition,  or  in 
the  poisoned  condition  of  the  blood.  When  the  delirium  of 
febrile  affections  appears,  the  headache  that  has  been  present 
disappears.  Headache  and  delirium  continue  together  in  menin- 
gitis. The  manifestations  of  irritation  and  paralysis  of  cranial 
nerves,  including  optic  neuritis  and  atrophy,  seen  in  meningitis, 
are  wanting  in  simple  febrile  disorders. 

How  is  cerebral  meningitis  to  be  distinguished  from  cerebro- 
spinal fever  ? 

The  differences  are  of  degree,  extent  and  etiology.  When 
the  membranes  of  the  brain  are  inflamed,  the  spinal  mem- 
branes are  usually  in  some  degree  also  involved.  Cerebro-spinal 
fever  is  considered  a  constitutional  affection,  cerebral  meningitis 
a  local  affection.  In  the  former,  however,  the  spinal  involve- 
ment stands  boldly  out,  as  evidenced  by  the  tendency  to  opis- 
thotonos, the  symptoms  on  the  part  of  the  trunk,  the  sphinc- 
ters, and  the  lower  extremities  ;  while  the  latter  is  especially 
marked  by  the  involvement  of  cerebral  structures.  Cutaneous 
eruptions  mark  cerebro-spinal  fever,  but  are  no  part  of  cerebral 
meningitis.  The  recognition  of  a  cause  of  cerebral  meningitis, 
or  a  knowledge  of  the  existence  of  other  cases  of  cerebro-spinal 
fever  may  determine  the  diagnosis.  The  detection  of  the 
specific  bacteria  of  cerebro-spinal  fever  in  the  fluid  obtained  by 
puncture  of  the  membranes  in  the  lumbar  region  affords  con- 
clusive evidence. 

How  is  cerebral  meningitis  to  be  distinguished  from  acute 
mania? 

The  mental  wandering  of  meningitis  does  not  usually  attain 
the  high  degree  seen  in  mania  ;  and  in  the  former  it  is  attended 
with  febrile  manifestations,  in  the  latter  not.  The  symptoms 
on  the  part  of  the  cranial  nerves,  the  headache,  the  convulsions 
of  meningitis  are  wanting  in  mania. 


HYDROCEPHALUS.  345 

Hydrocephalus. 

What  are  the  varieties  of  hydrocephalus  ? 

An  excessive  accumulation  of  cercbro-spinal  fluid  may  take 
place  in  the  subdural  space  or  within  the  ventricles  of  the 
brain.  The  one  condition  is  called  external;  the  other  internal 
hydrocephalus.  Either  may  be  acute  or  chronic,  primary  or  sec- 
ondary, congenital  or  acquired. 

What  are  the  causes  of  hydrocephalus  ? 

Hydrocephalus  may  be  a  result  of  meningitis,  of  obstruction 
of  the  orifices  of  communication  between  the  ventricles  and 
between  the  fourth  ventricle  and  the  subarachnoid  space,  or  of 
pressure  on  the  veins  of  Galen.  Occasionally  no  causative 
factor  is  recognizable. 

To  what  symptoms  does  hydrocephalus  give  rise  ? 

Occurring  in  a  child  prior  to  the  closure  of  the  sutures  and 
the  complete  ossification  of  the  bones,  hydrocephalus  causes  a 
separation  and  a  thinning  of  the  cranial  bones.  When  the 
fluid  distends  the  ventricles,  the  surrounding  cerebral  tissue 
becomes  attenuated.  Under  such  conditions  the  head  is  en- 
larged ;  the  fontanels  may  be  open  ;  the  eye-balls  roll ;  the  men- 
tal condition  is  defective  ;  there  is  muscular  weakness  ;  there 
may  be  convulsions  ;  and  various  cranial  nerves  may  be  para- 
lyzed. 

In  the  more  aggravated  cases  idiocy  exists  ;  there  is  blindness, 
with  choked  discs  ;  and  life  may  be  terminated  by  convulsions 
and  coma. 

Analogous  symptoms  also  occur  when  hydrocephalus  develops 
later  in  life. 

Hemorrhage  into  the  Cerebral  Membranes. 

What  are  the  varieties  of  hemorrhage  in  the  cerebral  meninges  ? 

The  extravasation  of  blood  without  the  dura  mater,  between 
the  dura  and  the  bone,  constitutes  extradural  hemorrhage  ; 
hemorrhace  within  the  dura  mater,  between  the  dura  and  arach- 


346  ESSENTIALS    OF    DIAGNOSIS. 

noid  is  called  suhdnral;   and  between  the  arachnoid  and  pia 
mater,  subarachnoid. 

Under  what  conditions  does  hemorrhage  into  the  meninges  of 
the  brain  occur  ? 
Hemorrhage  into  the  cerebral  membranes  may  be  a  result  of 
traumatism  ;  of  the  rupture  of  an  aneurism  of  a  meningeal  vessel ; 
of  the  rupture  of  a  hemorrhage  in  the  brain  ;  of  the  same  condi- 
tions as  occasion  cerebral  hemorrhage  ;  it  may  occur  in  the 
insane  ;  rarely  it  occurs  spontaneously. 

To  what  symptoms  does  hemorrhage  into  the  cerebral  mem- 
branes give  rise? 

The  symptoms  of  hemorrhage  into  the  cerebral  membranes, 
depend  upon  the  volume  and  the  extent  of  the  extravasation. 
The  symptoms  are  those  of  meningitis,  plus  those  of  cerebral 
hemorrhage,  and  may  be  preceded  by  headache,  vertigo  and 
vomiting. 

The  infantile  meningeal  hemorrhages  that  result  during  labor 
occasion  the  so-called  birth-palsies,  with  the  symptoms  of  con- 
genital spastic  paraplegia  or  hemiplegia. 

Congenital  Spastic  Paraplegia. 

What  is  infantile  or  congenital  spastic  paraplegia? 

When,  as  a  result  of  injury  to  the  child  during  birth,  bilateral 
meningeal  hemorrhage  takes  place  over  the  central  convolutions, 
the  pyramidal  tracts  fail  to  develop  or  they  degenerate.  The 
child  is  late  in  learning  to  walk.  It  presents  the  symptoms  of 
spastic  paraplegia.  The  gait  is  peculiar,  one  foot  being  placed 
over  or  in  front  of  the  other,  or  a  swinging  oscillation  taking  place. 
Growth  and  development  are  retarded.  Athetoid  movements 
in  the  hands  are  common.  Initial  convulsions  may  occur  and 
be  repeated,  subsequently  to  cease.  Should  the  hemorrhage  be 
circumscribed  or  unilateral,  the  distribution  of  the  symptoms 
will  vary  accordingly.  There  is  usually  defective  mental  de- 
velopment. 


CEREBRAL     ANEMIA.  347 

What  are  the  distinctions  between  congenital  spastic  para- 
plegia and  pseudo-hypertrophic  paralysis? 
The  reflexes  are  exaggerated  in  congenital  spastic  paraplegia, 
enfeebled  or  lost  in  pseudo-hypertrophic  paralysis.     The  gait  of 
congenital  spastic  paraplegia  is  spastic  ;  that  of  pseudo-hyper- 

FiG.  50. 


Case  of  cougenital  spastic  diplegia.     (Philadelphia  Hospital.) 

trophic  paralysis  is  oscillating ;  the  manner  in  which  the  child 
rises  from  the  floor  in  the  latter  is  characteristic.  In  congenital 
spastic  paraplegia  the  contractures  are  yielding  ;  in  pseudo- 
hypertrophic paral3'sis  unyielding  ;  the  former  is  retrogressive, 
the  latter  progressive.  Should  there  be  decided  enlargement  of 
some  of  the  muscles,  this  will  constitute  a  diagnostic  feature. 

Cerebral  Anemia. 

What  are  the  conditions  that  lead  to  cerebral  anemia? 

Anemia  of  the  hrain  may  be  general :  as  a  part  of  a  systemic 
anemia,  from  cardiac  iusufiiciency,  from  accumulation  of  blood 
elsewhere,  from  pressure  on  the  large  vessels  to  the  head,  from 
pressure  on  the  brain  ;  or  partial :  from  obstruction  of  the  circu- 
lation by  vascular  occlusion  or  by  pressure  from  without. 
Cerebral  anemia  may  develop  gradually  or  suddenly. 

To  what  symptoms  does  cerebral  anemia  give  rise  ? 

General  anemia  of  the  brain,  suddenly  induced,  occasions  the 


348  ESSENTIALS    OP    DIAGNOSIS. 

symptoms  of  syncope:  failure  of  vision,  ringing  in  the  ears, 
vertigo,  nausea,  shallow,  sighing  respiration,  contracted  pupils, 
pallor  of  the  face,  a  cool,  moist  skin  and  loss  of  consciousness. 
Nystagmus  and  convulsions  may  occur.  The  loss  of  conscious- 
ness may  pass  into  coma,  and  coma  into  death. 

General  anemia  of  the  brain,  gradually  induced,  occasions 
enfeeblement  with  irritability  of  function.  There  are  headache, 
vertigo,  impaired  intellection,  motor  weakness,  drowsiness  or 
insomnia,  hallucinations,  mania  or  melancholia.  The  optic 
disc  may  be  pale.  The  symptoms  are  aggravated  by  the  erect 
posture  and  may  be  mitigated  by  recumbency  or  inhalation  of 
amyl  nitrite. 

Partial  anemia  of  the  brain  is  followed  by  impaired  nutrition 
and  loss  of  function  in  the  affected  area.  Occurring  suddenly, 
it  is  attended  with  loss  of  consciousness  and  convulsions  ;  when 
of  gradual  development,  it  occasions  headache,  vertigo,  numb- 
ness, tingling  and  weakness. 

Cerebral  Hyperemia, 

What  conditions  lead  to  cerebral  hyperemia  ? 

Hyperemia  of  the  hrain  may  be  active  or  passive.  Active  hy- 
peremia  may  be  caused  by  an  overacting  left  ventricle  ;  by  sudden 
contraction  of  the  vessels  elsewhere  ;  by  insolation  ;  it  may  be 
part  of  a  general  plethoric  condition  ;  and  it  occurs  as  the  first 
stage  of  the  inflammatory  process. 

Passive  hyperemia  is  a  result  of  cardiac  insufficiency,  of  venous 
obstruction  as  a  result  of  pressure  from  without  or  of  pulmonary 
disease. 

To  what  symptoms  does  cerebral  hyperemia  give  rise  ? 

The  symptomatology  of  cerebral  hyperemia  is  somewhat 
obscure.  The  recognition  of  the  condition  is  not  always  easy. 
Usually  there  are  dull  headache,  a  sense  of  fulness  of  the  head, 
vertigo,  mental  torpor,  derangement  of  sleep,  a  disinclination  to 
activity,  flashes  of  light  and  tinnitus  aurium.  The  countenance 
may  be  flushed  ;  the  vessels  of  the  eyeground  injected.  There 
may  be  transient  loss  of  consciousness.  Convulsions  are  un- 
common. 


CEREBRITIS  —  CEREBRAL    ABSCESS.  349 


Cerebritis. 

What  are  the  clinical  features  of  cerebritis  ? 

Injianimation  of  the  structure  of  the  hrain  may  be  acute  or 
chronic.  It  is  usually  a  result  of  traumatism,  or  it  may  arise 
by  extension  from  adjacent  disease.  Some  degree  of  cerebritis 
is  coincident  with  inflammation  of  the  membranes.  Tlie  symp- 
toms are  rather  obscure  a<nd  ill-defined.  There  are  headache, 
vertigo,  delirium,  convulsions  and  febrile  symptoms.  Cerebritis 
may  be  followed  by  abscess. 

How  is  inflammation  of  the  membranes  to  be  distinguished 
from  inflammation  of  the  structure  of  the  brain  ? 

Inflammation  of  the  membranes  and  inflammation  of  the 
structure  of  the  brain  are  to  some  degree  always  associated,  the 
symptoms  of  either  condition  respectively  predominating.  In- 
flammation of  brain-tissue,  however,  is  usually  attended  with 
symptoms  more  profound  and  more  depressing  than  are  those 
of  meningitis ;  while  the  symptoms  of  meningitis  are  usually 
more  widel}'  distributed  and  more  irritative  in  character. 

Cerebral  Abscess. 

What  are  the  causes  of  abscess  of  the  brain  ? 

The  development  of  cerebral  abscesses  is  usually  dependent 
upon  traumatism,  suppurative  disease  of  adjacent  structures  or 
P3^emia.  Distant  suppuration  may  give  rise  to  embolic  abscess. 
Inflammation  of  the  brain  may  terminate  in  suppuration  and 
the  formation  of  an  abscess.  Cerebral  abscess  may  be  acute  or 
chronic  in  its  course  ;  it  may  be  single  or  multiple. 

What  are  the  symptoms  of  abscess  of  the  brain  ? 

The  symptoms  of  abscess  of  the  hrain  present  themselves  in 
three  stages  :  a  primary  acute  stage,  in  which  the  symptoms  of  the 
associated  condition  may  obscure  the  cerebral  s3niiptoms  ;  a 
secondary  stage  of  lull,  in  which  the  symptoms  are  latent  and  in 
abeyance  ;  and  a  terminal  stage,  in  which  rupture  of  the  abscess 
gives  rise  to  the  abrupt  appearance  of  the  signs  of  meningitis, 


350  ESSENTIALS    OP    DIAGNOSIS. 

of  cerebritis  or  of  apoplexy,  followed  by  stupor,  coma  and  death. 
These  stages  are  not  always  distinct.  Commonly  the  one  passes 
by  gradations  into  the  other. 

The  more  obvious  symptoms  are  fever,  recurrent  rigors,  head- 
ache (which  may  be  localized),  vertigo,  vomiting  and  optic 
neuritis  (which  are  most  marked  in  cerebellar  abscess),  epilep- 
tiform convulsions  and  paralysis  (when  the  abscess  is  seated  in 
the  motor  area).  There  may  be,  in  addition,  unilateral  ptosis, 
defect  of  speech,  impairment  of  articulation,  difficulty  of  deglu- 
tition and  mental  disturbance. 

From  what  conditions  is  abscess  of  the  brain  to  be  differen- 
tiated? 

Abscess  of  the  brain  gives  rise  to  many  of  the  symptoms  of 
tumor  of  the  brain.  In  the  terminal  stage  it  occasions  tlie 
symptoms  of  meningitis,  of  cerebritis  or  of  apoplexy.  The  dis- 
tinction from  these  several  conditions  depends  upon  the  recog- 
nition of  a  cause  of  abscess,  upon  the  recurrence  of  chills,  upon 
the  presence  of  febrile  symptoms.  The  headache  and  optic 
neuritis  of  tumor  are  more  intense  than  those  of  abscess.  In 
meningitis  there  is  greater  involvement  of  cranial  nerves  than 
in  abscess.  The  course  of  the  symptoms  of  abscess  is  of  longer 
duration  than  is  the  case  in  cerebritis.  Optic  neuritis  is  wanting 
in  apoplexy.  The  symptoms  of  the  terminal  stage  of  abscess 
are  to  be  distinguished  from  meningitis,  cerebritis  and  apoplexj'- 
by  a  knowledge  of  the  previous  existence  of  obscure  symptoms 
of  cerebral  disease. 

Cerebral  Hemorrhage. 

What  are  the  causes  of  cerebral  hemorrhage  ? 

The  ultimate  cause  of  cerebral  hemorrhage,  not  traumatic 
in  origin,  is  disease  of  the  bloodvessels.  The  event  may  be 
induced  by  over-action  of  the  heart.  In  some  cases  of  cerebral 
hemorrhage,  an  hereditary  tendency  can  be  elicited.  Hemor- 
rhage in  the  brain  is  most  common  at  the  degenerative  period 
of  life,  and  its  freqency  increases  with  age  ;  the  condition  occurs 
more  commonly  in  males  than  in  females  ;  in  temperate  than  in 


CEREBRAL    HEMORRHAGE 


351 


tropical  climates  ;  in  winter  than  in  summer.  The  antecedent 
disease  of  the  vessels  may  depend  upon  alcoholism,  gout,  rheu- 
matism, syphilis,  nephritis,  lead-poisoning,  infectious  diseases 
and  blood-diseases. 

What  is  the  pathology  of  cerebral  hemorrhage  ? 

The  symptoms  that  follow  the  occurrence  of  cerebral  hemor- 
rhage depend  upon  laceration  of  the  brain-tissue,  and  upon  the 
compression  and  irritation  of  adjacent  structure  to  which  the 
extravasation  gives  rise.  In  the  course  of  time,  the  blood,  as 
well  as  the  products  of  disintegration,  are  absorbed,  until  there 
remains  to  mark  the  previous  hemorrhage  nothing  but  a  fibrous 
cicatrix  or  a  cyst.  The  conducting  motor  fibers  related  to  the 
structures  destroyed  undergo  secondary  degeneration. 

Fig.  51. 


Cerebral  miliary  aneurisms.    (Eichhorst.) 

The  most  frequent  seat  of  cerebral  hemorrhage  is  the  region 
of  the  central  ganglia  ;  next  in  frequency  is  the  centrum  ovale  ; 
then  the  cortex,  pons  and  cerebellum. 

What  are  the  symptoms  of  cerebral  hemorrhage? 

The  occurrence  of  hemorrhage  in  the  brain  is  indicated  by 
sudden,  complete  loss  of  consciousness,  with  general  muscular 
relaxation,  and  depression  of  temperature.  True  prodromata 
are  wanting.  The  breathing  is  labored  and  stertorous  ;  an 
initial  convulsion  may  occur  ;  the  pulse  is  apt  to  be  slow,  full 
and  hard  ;  the  pupils  unequal ;  the  reflexes  abolished  or  unequal ; 


352  ESSENTIALS    OF    DIAGNOSIS. 

and  the  head  and  eyes  deviated  to  one  side  (conjugate  deviation). 
Urine  and  feces  may  be  passed  invokmtarily.  The  urine  may 
contain  albumin,  or  even  sugar.  Vomiting  may  occur.  As  the 
shock  of  the  seizure  passes  off  consciousness  slowly  returns  and 
the  evidences  of  hemiplegia  become  apparent.  The  leg,  the 
arm,  perhaps  the  face,  are  paralyzed  on  the  side  opposite  to 
that  on  which  the  lesion  is  situated.  The  tongue,  protruded, 
deviates  to  the  paralyzed  side.  There  is  difficulty  in  degluti- 
tion, in  phonation,  in  articulation.  There  may  be  partial  or 
complete  anesthesia  of  the  paralyzed  members.  Secondarj'- 
fever  appears.  Gradual  improvement  slowly  takes  place,  in 
greatest  degree  in  those  parts  that  habitually  act  in  association 
with  corresponding  parts  of  the  opposite  side. 

If  the  hemorrhage  occur  in  the  cortex,  epileptiform  convul- 
sions take  place  ;  if  in  the  posterior  part  of  the  third  frontal  con- 
volution of  the  left  side,  aphasia  results  ;  if  in  the  posterior  part 
of  the  first  temporal  convolution,  word-deafness  ;  if  in  the 
angular  gyrus  and  occipital  lobe,  hemianopsia  and  word-blind- 
ness ;  if  in  the  anterior  part  of  the  uncinate  convolution,  loss 
of  the  sense  of  taste.  If  the  hemorrhage  is  large  and  extensive 
the  patient  may  never  emerge  from  the  primary  coma,  but  death 
may  speedily  or  slowiy  take  place.  Implication  of  the  pons  or 
medulla  is  indicated  by  abnormal  elevation  of  temperature.  In 
most  cases  the  hemorrhage  involves  the  region  of  the  central 
ganglia  and  the  internal  capsule. 

Athetosis,  post-hemiplegic  chorea  and  other  spasmodic  condi- 
tions may  be  sequelae  of  cerebral  hemorrhage.  The  reflexes  be- 
come exaggerated,  especially  upon  the  paralyzed  side,  as  a  result 
of  descending  degeneration  of  the  pyramidal  tracts.  The  memory 
is  impaired.  Emotional  mobility  is  increased.  Various  vaso- 
motor and  trophic  changes  may  take  place  in  the  affected  parts, 
which  may  also  become  fixed  by  contractures. 

In  what  respects  do  the  symptoms  of  cerebral  hemorrhage 
differ  from  those  of  cerebral  congestion  ? 

Cerebral  congestion  may  be  attended  with  transient  loss  of 
consciousness,  not  so  profound,  however,  as  is  the  case  in 
hemorrhage.  The  event  is  prone  to  be  repeated,  but  the  con- 
dition does  not  give  rise  to  permanent  paralytic  manifestations. 


CEREll  llAf,    II  KM  ORR  IT  AfJE.  353 

What  are  the  distinctions  hetween  the  loss  of  consciousness  of 
syncope  and  that  of  cerebral  hemorrhage  ? 

S3'ncope  is  usually  a  result  of  cerebral  anemia,  induced  by 
insufficiency  of  the  circulation  ;  it  may  also  result  from  ner- 
vous influences  that  stimulate  the  vagus.  The  loss  of  con- 
sciousness is  of  but  brief  duration.  The  pulse  is  feeble,  the 
face  pale,  the  breathing  shallow  and  sighing.  The  reflexes  are 
preserved.  The  sphincters  are  continent.  The  return  to  con- 
sciouness  is  not  attended  with  evidences  of  paralysis.  The 
attack  is  prone  to  be  repeated. 

How  is  the  coma  of  cerebral  hemorrhage  to  be  distinguished 
from  the  coma  of  alcoholic  intoxication  ? 
The  symptoms  of  cerebral  hemorrhage  come  on  suddenly  ; 
those  of  alcoholic  coma,  less  suddenlj^,  as  a  direct  consequence 
of  the  imbibition  of  a  toxic  quantitj-  of  alcohol.  The  coma  of 
alcoholism  is  not  so  profound  as  that  of  hemorrhage.  It  may 
be  possible  by  appropriate  stimuli  to  rouse  an  individual  over- 
come by  alcohol,  but  there  is  no  response  from  the  coma  of 
hemorrhage.  The  odor  of  alcohol  in  the  breath,  and  the  detec- 
tion of  alcohol  in  the  urine  would  be  doubtful  evidence  ;  but 
the  absence  of  these  conditions  would  exclude  alcoholism. 
Conjugate  deviation  of  the  head  and  eyes  is  a  common  feature 
of  hemorrhage  ;  alcoholism  will  not  cause  it.  The  pupils  are 
usually  dilated  in  alcoholism,  not  contracted  and  unequal  as 
in  hemorrhage.  The  temperature-alterations  of  hemorrhage 
are  wanting  in  alcoholic  intoxication.  On  the  return  of  con- 
sciousness after  alcoholic  coma,  there  is  no  palsy  ;  palsy  is 
characteristic  of  hemorrhage. 

How  is  the  coma  of  cerebral  hemorrhage  to  be  distinguished 
from  that  of  opium-poisoning? 

In  the  absence  of  the  previous  history,  cerebral  hemorrhage 
is  to  be  distinguished  from  opium-poisoning  by  the  primary 
depression  and  secondary  elevation  of  temperature,  by  the  con- 
jugate deviation  of  the  head  and  eyes,  by  the  evidences  of  par- 
al3'sis. 

The  small  pupils  of  opium-poisoning  are  equal ;  if  hemorrhage 
causes  contraction  of  the  pupils,  one  is  likely  to  be  smaller  than 
23 


354  ESSENTIALS    OF    DIAGNOSIS. 

the  other.     The  noisy  breathing  of  hemorrhage  does  not  become 
so  infrequent  as  the  breathing  in  opium-poisoning. 

How  is  uremia  to  be  distinguished  from  cerebral  hemorrhage  ? 

The  conditions  under  which  uremia  develops  predispose  to 
the  occurrence  of  cerebral  hemorrhage.  The  recognition  of  dis- 
ease of  the  kidney  does  not  help  in  diagnosis.  The  coma  of 
hemorrhage,  however,  is  likely  to  set  in  more  suddenly  and  to 
be  more  profound  than  is  that  of  uremia. 

Uremia  is  more  likely  than  hemorrhage  to  appear  in  young 
persons.  The  convulsions  that  attend  uremia  are,  as  a  rule, 
general ;  unilateral  convulsions  are  more  likely  to  be  indicative 
of  cerebral  hemorrhage.  The  primary  depression  of  temper- 
ature is  followed  bj^  a  secondary  elevation  in  hemorrhage,  but 
usually  not  in  uremia.  Inequality  of  the  pupils  and  conjugate 
deviation  of  the  head  and  eyes  are  indicative  of  hemorrhage 
rather  than  of  uremia. 

If  loss  of  muscular  power  follow  uremia,  it  is  usually  circum- 
scribed and  transitory  ;  in  hemorrhage  it  is  usually  hemiplegic 
and  persistent. 

In  uremia  the  tongue  is  dry  and  covered  with  a  thick  brown- 
ish fur ;  there  is  often  vomiting ;  the  body  often  exhales  a  pecu- 
liar, musty  odor,  not  observed  in  hemorrhage. 

Howls  asphyxiate  be  distinguished  from  cerebral  hemorrhage? 
When  an  individual  is  asphyxiated  from  whatever  cause,  the 
appearance  is  cyanotic.  Respiration  is  interfered  with,  but  is 
not  noisy.  There  is  no  conjugate  deviation  of  the  head  and 
eyes.  Measures  of  resuscitation  may,  in  a  little  while,  prove 
successful,  while  the  paralytic  phenomena  attendant  upon 
cerebral  hemorrhage  are  absent. 


Cerebral  Softening. 

What  are  the  varieties  of  softening  of  the  brain  ? 

Softening  of  the  hrain  may  be  acute  or  chronic.  Acute  soften- 
ing of  the  hrain  may  be  a  result  of  inflammation  ;  it  may  follow 
vascular  occlusion,  thrombotic  or  embolic,  arterial  or  venous. 


CEREBRAL    EMBOLISM.  355 

Chronic  softening  of  the  brain  is  an  aftection  of  the  degenera- 
tive period  of  life.  It  usually  involves  the  white  matter  of  the 
hemispheres.  The  S3'mptoms  to  which  it  gives  rise  are  not 
well  defined.  There  is  usually  progressive  loss  of  motor  power 
and  impairment  of  sensation,  sometimes  with  rigidity.  Mental 
deterioration  may  be  slight  or  considerable.  Life  may  be  pro- 
longed for  from  two  months  to  two  years,  death  usually  result- 
ing from  bedsores,  pneumonia,  or  some  other  intercurrent 
malady. 

Cerebral  Embolism. 

Under  what  conditions  does  cerebral  embolism  occur  ? 

A  vegetation  from  a  diseased  cardiac  valve  may  be  w^ashed 
into  one  of  the  vessels  of  the  brain  ;  or  the  plug  ma}'  have  its 
source  in  a  thrombus  that  has  formed  in  one  of  the  cavities  of 
the  heart,  or  in  a  calcareous  fragment  from  the  wall  of  an 
atheromatous  aorta. 

To  what  symptoms  does  cerebral  embolism  give  rise? 

The  sudden  plugging  of  one  of  the  vessels  of  the  brain  is 
usually  manifested  by  transient  loss  of  consciousness  of  varying 
duration,  often  accompanied  by  convulsions.  On  the  return  to 
consciousness,  the  sj-mptoms  of  hemiplegia  are  evident,  often 
right-sided,  and  associated  with  aphasia.  In  the  course  of  a 
few  days,  secondary  fever  appears.  Unilateral  convulsions 
may  be  repeated.  Choreoid,  athetoid,  and  other  disorders  of 
movement  are  likely  to  develop. 

How  do  the  symptoms  of  cerebral  hemorrhage  differ  from 
those  of  cerebral  embolism? 

Cerebral  embolism  is  a  disease  rather  of  early  life  ;  hemor- 
rhage is  one  of  advanced  life.  Hemorrhage  occurs  in  association 
with  disease  of  the  vessels  ;  embolism  with  valvular  disease  of 
the  heart  or  other  source  of  emboli.  Consciousness  is  invariably 
lost  when  hemorrhage  takes  place  ;  it  is  more  likely  not  to  be 
in  cases  of  embolism.  Embolism  is  more  likely  to  be  cortical 
and  to  give  rise  to  initial  and  consecutive  epileptiform  convul- 
sions, to  localized  palsies  and  to  aphasia  ;  hemorrhage  is  more 


356  ESSENTIALS    OF    DIAGNOSIS. 

likely  to  be  central,  to  be  unattended  with  convulsions,  and  to 
present  hemiplegia.  Both  direct  (local)  and  indirect  (general) 
symptoms  are  more  profound  and  more  extensive  in  hemorrhage 
than  in  embolism.  The  detection  of  emboli  in  other  organs  is 
an  important  element  in  diagnosis. 


Cerebral  Thrombosis. 

Under  what  conditions  does  cerebral  thrombosis  occur? 

The  most  common  cause  of  cerebral  thrombosis  is  vascular 
disease,  whether  atheromatous,  syphilitic  or  fibroid.  The  blood 
may  also  coagulate  in  the  vessels  in  conditions  of  lowered 
vitality  and  enfeebled  circulation.  Increased  coagulability  of 
the  blood  predisposes  to  the  occurrence  of  thrombosis.  A 
thrombus  may  form  from  an  embolus  by  extension. 

To  what  symptoms  does  cerebral  thrombosis  give  rise? 

The  actual  occurrence  of  thrombosis  in  a  cerebral  vessel  may 
for  a  long  time  be  preceded  by  distressing  headache,  vertigo, 
numbness,  tingling,  muscular  weakness,  impairment  of  memory 
and  mental  failure.  The  formation  of  the  thrombus  is  announced 
by  loss  of  consciousness,  of  varying  degree  and  duration,  per- 
haps attended  with  convulsions  or  with  delirium.  In  the  course 
of  a  few  days,  decided  secondary  fever  may  appear.  Subse- 
q^uently,  the  evidences  of  hemiplegia  become  manifest ;  while 
recurring  localized  convulsions  may  take  place.  As  in  the  case 
of  embolism,  involuntary  and  spasmodic  disorders  of  movement 
in  the  affected  parts  are  common.  Thrombosis  of  the  sinuses 
gives  rise  to  localized  edema  of  the  face  and  scalp. 

How  are  cerebral  hemorrhage  and  cerebral  thrombosis  to  be 
differentiated  ? 

Thrombosis,  unlike  hemorrhage,  is  of  not  rare  occurrence  in 
infancy  and  extreme  old  age.  The  symptoms  of  hemorrhage  set 
in  suddenly,  with  loss  of  consciousness  ;  those  of  thrombosis  are 
preceded  by  prodromata  and  develop  gradually,  with  headache, 
delirium,  perhaps  convulsions.  The  convulsions  of  thrombosis 
are  wont  to  be  localized  or  unilateral ;  if  convulsions  attend 


CEREBRAL    TUMOR.  357 

hemorrhage,  they  are  usually  general.  Hemorrhage  is  the  more 
likely  to  occur  under  conditions  of  excitement ;  thrombosis,  amid 
conditions  of  depression.  In  hemorrhage  the  circulation  is 
active,  the  arterial  tension  high  ;  thrombosis  is  not  uncommonly 
associated  with  a  stagnant  circulation  in  a  debilitated  indi- 
vidual. The  symptoms  are  more  profound  and  extensive  in 
hemorrhage  than  in  thrombosis.  Mobile  spasm,  athetosis  and 
other  disorders  of  movement  more  commonly  follo\Y  thrombosis 
than  hemorrhage.  Recurrent  convulsions  also  point  to  throm- 
bosis rather  than  to  hemorrhage. 


Cerebral  Tumor. 

What  are  the  more  commoii  varieties  of  tumor  of  the  brain  ? 

Cerebral  tumors  are  most  commonly  gliomata,  tuberculomata, 
sarcomata,  gummata,  myxomata,  carcinomata  or  psammomata. 
They  may  develop  in  the  cerebral  mass,  in  the  membranes,  or 
in  the  bone. 

Xot  rarely,  cysticerci  or  echinococcus  cysts  develop  in  the 
brain.     Gliomata  sometimes  follow  injuries  to  the  head. 

Tuberculomata  appear  in  young  persons,  and  are  usually 
associated  with  tuberculosis  elsewhere  than  in  the  brain.  Car- 
cinomata occur  later  in  life,  give  rise  to  a  cachexia,  and  are 
associated  with  similar  growths  elsewhere.  Gummata  are 
present  with  other  manifestations  and  a  history  of  syphilis. 

What  are  the  symptoms  of  tumor  of  the  brain  ? 

The  symptoms  vary  somewhat  with  the  size  and  situation  of 
the  new-growth.  Certain  phenomena,  however,  characterize 
the  presence  of  a  neoplasm  in  any  part  of  the  brain.  There  is 
persistent  headache,  intensely  aggravated  in  paroxysms  ;  optic 
neuritis  followed  by  atrophy  ;  mental  failure  ;  impaired  memory  ; 
emotional  mobility  ;  vomiting  ;  vertigo  ;  sometimes  forced  move- 
ments ;  slowness  of  speech  ;  separation  of  syllables ;  confluence 
of  articulation  ;  sometimes  aphasia  ;  paralysis  of  varying  dis- 
tribution, associated  with  or  followed  by  contractions  ;  some- 
times choreoid  or  athetoid  movements,  or  a  jerky  incooordi- 
nation  ;   convulsions   resembling   those   of  major  or  of  minor 


358  ESSENTIALS    OF    DIAGNOSIS. 

epilepsj?-,  or  of  Jacksoiiian  epilepsy,  or  attacks  of  transient 
convulsions  ;  alterations  of  sensation  ;  palsy  of  cranial  nerves ; 
sometimes  conjugate  deviation  of  the  head  and  eyes  ;  abnor- 
malities of  the  pulse  ;  interference  with  the  respiration.  The 
quantity  of  urine  evacuated  may  be  increased  ;  there  may  be 
albuminuria  or  glycosuria.  Finally,  stupor  and  coma  may  be 
the  precursors  of  death. 

How  may  chronic  nephritis  simulate  cerebral  tumor ;  how  are 
the  two  to  be  differentiated  ? 

Chronic  nephritis  may  be  attended  with  headache,  vertigo, 
vomiting,  optic  neuritis  and  convulsions,  but  the  urine  con- 
tains casts  as  well  as  albumin,  edema  exists,  the  arterial  tension 
is  heightened,  the  heart  is  hypertrophied,  and  the  palsies  of 
tumor  are  wanting. 

What  symptoms  does  anemia  have  in  common  with  tumor  of 
brain,  and  how  are  the  two  to  be  differentiated  ? 

Both  anemia  and  cerebral  tumor  may  occasion  headache, 
vertigo,  optic  neuritis  and  albuminuria,  but  the  headache  of 
anemia  is  not  so  intense  as  that  of  tumor ;  the  optic  neuritis  of 
anemia  is  more  rapid  in  development  than  is  that  of  tumor ; 
while  the  pallor,  the  breathlessness,  the  edema,  the  submissive- 
ness  to  judicious  treatment  of  the  one,  and  the  convulsions,  the 
palsies,  the  progressiveness,  and  the  resistance  to  treatment  of 
the  other  are  distinctive. 

How  are  the  epileptiform  convulsions  of  cerebral  tumor  to  be 
distinguished  from  the  convulsions  of  essential  epilepsy  ? 
In  themselves  the  convulsions  may  be  indistinguishable, 
though  those  of  tumor  are  the  more  likely  to  be  local  or  uni- 
lateral. Epilepsy,  however,  fails  to  present  the  distinctive 
symptoms  of  tumor  :  headache,  vertigo,  vomiting,  optic  neuritis 
and  palsies. 

How  may  the  symptoms  of  cerebral  tumor  be  mistaken  for 
those  of  cerebro-spinal  sclerosis ;  how  is  the  diagnosis  to 
be  made  ? 

A  tumor  in  the  brain  may  occasion  a  peculiar  jerky  incoordi- 
nation, but  it  does  not  occasion  the  nystagmus,  the  peculiarity 


GENERAL    PARALYSIS    OF    THE    INSANE.  359 

of  speech,  the  exaggeration  of  reflexes  of  cerebro-spinal  sclerosis, 
while  headache  and  optic  neuritis  are  more  common  and  more 
intense. 

Intracranial  Aneurism, 

To  what  symptoms  does  an  intracranial  aneurism  give  rise  ? 

Aneurism  of  the  cerebral  vessels  may  develop  as  a  result  of 
vascular  disease,  syphilitic  or  otherwise,  of  traumatism  and  of 
embolism. 

The  symptoms  of  intracranial  aneurism  necessarily  vary  with 
the  situation  of  the  aneurism.  The  more  constant  symptoms 
are  those  of  an  intracranial  tumor :  headache,  vertigo,  vomiting, 
convulsions,  palsies,  optic  neuritis.  The  detection  of  a  bruit  or 
the  demonstration  of  symptoms  dependent  upon  the  presence 
of  a  tumor  in  the  course  of  a  cerebral  vessel  would  be  diagnostic. 

The  occurrence  of  rupture  is  indicated  by  the  symptoms  of 
cerebral  hemorrhage. 

General  Paralysis  of  the  Insane. 

What  are  the  symptoms  of  general  paralysis  of  the  insane? 

General  or  progressive  paralysis  of  the  insane,  or  paretic  dementia, 
is  a  fatal  disease  of  insidious  invasion,  occurring  in  those  who 
have  abused  their  mental  and  physical  energies,  and  charac- 
terized b}^  psychic  alteration  and  failure,  with  progressive  palsy. 

Syphilis  also  is  a  most  imiDortant  etiologic  factor.  The  dis- 
ease is  much  more  common  in  men  than  in  women,  and  in 
early  middle  life  than  at  any  other  period. 

Among  the  first  symptoms  are  an  alteration  of  disposition, 
and  a  change  of  character.  An  individual,  previously  more  or 
less  refined,  affectionate,  attentive,  scrupulous,  methodical,  pre- 
cise and  neat,  becomes  careless,  indifterent,  negligent,  coarse, 
indecent,  irritable  and  forgetful.  He  fails  to  keep  appointments. 
He  makes  ill-judged  investments  and  extravagant  expenditures. 
He  eats  irregularly  and  hastily,  and  sometimes  eats  and  drinks 
excessively,  and  sleeps  poorly. 

The  palsy  is  not  of  the  ordinary  type.  There  is  at  first  loss 
of  coordinating  power  for  delicate   tasks,  such  as  writing   or 


360  ESSENTIALS    OF   DIAGNOSIS. 

painting,  while  general  muscular  strength,  as  for  lifting,  is  but 
slightly  impaired.  The  paral3'sis  is  associated  with  tremor. 
The  pupils  may  be  contracted,  sluggish  and  unequal. 

To  these  symptoms  are  added  the  so-called  delusions  of  gran- 
deur, which  vary  from  time  to  time.  The  patient  believes  him- 
self fabulously  wealthy.  Pie  projects  colossal  enterprises,  or 
announc'es  wonderful  discoveries.  He  is,  however,  contented 
with  his  surroundings.  In  a  milder  form,  the  delusions  take 
the  less  obtrusive  shape  of  an  invincible,  unreasoning  optimism, 
aiid  may  be  overlooked.  In  other  cases  there  are  alternations 
of  depression  and  exaltation.  Sleeplessness  becomes  more  obsti- 
nate. Speech  becomes  defective,  indistinct  and  stuttering.  In 
writing,  words,  syllables,  letters  are  omitted  or  misplaced  or 
repeated.  There  is  a  peculiar  tremor  of  the  lips.  The  protruded 
tongue  presents  both  rhythmical  tremor  and  hbrillary  contrac- 
tions. The  gait  becomes  shuffling.  Control  over  the  limbs  is 
progressively  lost.  At  this  stage,  apoplectiform  and  epileptiform 
seizures  may  take  place,  and  paroxysms  of  rage  and  fury  may 
occur.  Sensibility  is  not  impaired  until  late,  when  it  may  be 
almost  abolished. 

Deceptive  lulls  and  remissions  may  interrupt  the  progress  of 
the  disease,  but  finally  a  condition  of  terminal  dementia  is 
reached.  Nutrition  gradually  fails.  Paralysis,  mental  and  phy- 
sical, becomes  so  great  that  death  may  result  from  the  entrance 
of  food  into  the  air-passages.  Coma,  convulsions,  painful  con- 
tractions, obstinate  diarrhea,  pulmonary  affections,  especially 
pneumonia,  are  among  the  phenomena  preceding  death.  At 
the  autopsy  chronic  congestive,  inflammatory  and  degenerative 
changes  may  be  found  in  the  brain  and  membranes  and  in  the 
posterior  and  lateral  columns  of  the  spinal  cord. 

How  are  progressive  paralysis  of  the  insane  and  posterior  spinal 
sclerosis  to  be  differentiated  ? 

As  the  symptoms  of  posterior  spinal  sclerosis  may  be  super- 
added to  those  of  progressive  paralysis  of  the  insane,  the  dif- 
ferentiation of  uncomplicated  cases  from  locomotor  ataxia,  as 
from  cerebro-spinal  sclerosis  and  paralysis  agitans,  essen- 
tially depends  upon  a  recognition  of  the  presence  or  absence 


SUNSTROKE.  361 

of  those  manifestations  of  central  dissolutional  processes  that 
characterize  progressive  paralysis  :  the  changes  in  character 
and  disposition,  the  emotional  disturbances,  the  impairment  of 
memory,  the  maniacal  outbursts,  the  delusions  of  grandeur, 
the  peculiar  tremor  of  lips  and  tongue,  the  inequality  of  the 
pupils,  the  derangement  of  the  language-faculty  in  speech  and 
writing,  the  progressive  failure  of  voluntary  motion  and  intel- 
lection, the  epileptiform  and  apoplectiform  attacks. 

Acute  development  of  the  peculiar  loss  of  coordinating  power, 
mental  and  physical,  without  obvious  cause,  in  a  man  of  middle 
life,  especially  one  given  to  mental,  emotional,  venereal  or  alco- 
holic excess,  or  with  a  history  of  syphilis,  should  at  once  excite 
a  suspicion  of  the  development  of  paretic  dementia. 

Sunstroke. 

What  are  the  symptoms  of  sunstroke  ? 

Sunstroke,  heat-stroke,  insolation,  of  which  there  are  at  least 
two  principal  varieties,  heat-fever  or  thevinic  fever  mid  heat-exhaus- 
tion— is  an  affection  of  the  heated  term.  It  occurs  in  persons 
exposed  to  intense  heat,  solar  or  artificial,  in  whom  the  respira- 
tory and  cutaneous  transpiration  is  checked. 

Crowding  and  defective  ventilation  predispose  to  the  occur- 
rence of  heat-stroke.  The  miset  may  be  abrupt  or  gradual,  the 
symptoms  severe  or  mild  (incomplete).  AVhile  most  often  com- 
ing on  during  active  muscular  exertion,  as  in  the  case  of 
laborers  and  marching  soldiers,  the  attack  not  infrequently 
follows  the  mid-day  meal.  It  usually  but  not  invariably 
happens  during  the  period  of  maximum  heat  of  the  day. 

There  occur  increased  frequency  of  micturition,  headache, 
vertigo,  nausea,  vomiting,  delirium,  loss  of  consciousness,  dys- 
phagia, stertorous  breathing  and  coma,  associated  in  the  febrile 
form  with  a  hot,  often  flushed,  skin,  frequent  pulse  and  high  tem- 
perature. The  pupils  may  be  dilated  or  contracted,  or  contrac- 
tion and  dilatation  may  be  present  at  different  times  in  the  same 
case.  There  ma}^  be  rectal  and  vesical  incontinence,  sometimes 
partial  suppression  of  urine.  The  duration  of  the  symptoms 
varies  from  a  few  minutes  to  several  hours. 


362  ESSENTIALS    OF   DIAGNOSIS. 

Death  may  occur  early  or  late  ;  recovery  may  be  speedy  or 
tardy.  Persistent  headache,  vesical  irritability,  choreoid  move- 
ments of  the  upper  extremities,  mental  impairment,  epilepsy, 
and  in  rare  instances  hemiplegia,  or  other  paralysis,  usually 
transient,  may  supervene  as  sequelae.  Anhydrosis,  with  headache 
and  elevation  of  temperature,  annually  recurring  near  the  anni- 
versary of  the  attack,  has  been  observed. 

General  paralysis  of  the  insane  (paretic  dementia)  has  been 
attributed  to  sunstroke. 

What  are  the  principal  points  of  differentiation  between  heat- 
exhaustion  and  heat-fever,  or  sunstroke  proper  ? 

In  heat-exhaustion  the  skin  is  pale,  cool  or  cold,  moist  or 
clammy  ;  the  temperature  is  low,  even  subnormal ;  there  is 
syncope  rather  than  coma  ;  the  pupils  are  usually  dilated  ;  the 
pulse  is  feeble  ;  convulsions  are  absent ;  and  rapid  relief  follows 
the  use  of  warmth  and  stimulants. 

How  does  cerebral  hemorrhage  differ  from  sunstroke  ? 

The  coma  of  sunstroke,  unlike  that  of  cerebral  hemorrhage, 
does  not  set  in  unannounced  ;  nor  is  it  as  lasting  or  as  profound  ; 
while  dysphagia  may  be  greater,  stertor  is  less. 

The  symptoms  of  sunstroke  are  symmetrical ;  the  pupils  and 
the  reflexes  are  equal ;  hemiplegia  is  not  an  ordinary  sequel. 

The  temperature  rises  much  higher  in  insolation  than  at  anj'- 
time  in  hemorrhage.  The  pulse  is  frequent,  often  feeble  ;  that 
of  cerebral  hemorrhage  is  commonly  slow  and  full. 

It  must,  however,  not  be  forgotten  that  cerebral  hemorrhage 
may  occur  amid  circumstances  favorable  for  the  development  of 
sunstroke. 

With  what  other  conditions  might  sunstroke  he  confounded  ? 

Sunstroke  might  be  mistaken  for  acute  alcoholism,  meningitis, 
uremia  or  narcotic  poisoning.  Alcoholic  excess  may  bring  on 
an  attack,  so  that  the  phenomena  of  both  might  be  intermingled. 
The  history  and  the  symptoms  detailed  should  prevent  error  in 
other  cases. 

In  uremia,  too,  convulsions  usually  precede  coma. 


DELIRIUM    TREMENS.  363 


Delirium  Tremens. 

What  are  the  symptoms  of  delirium  tremens  ? 

The  continued  ingestion  of  excessive  quantities  of  alcohol 
sometimes  gives  rise  to  a  condition  in  which  with  impaired 
appetite  and  gastric  irritability  are  associated  inability  to 
sleep,  tremor  and  delirium.  The  temperature  is  likely  to  be 
elevated.  The  urine  may  contain  albumin.  The  patient  is 
restless  and  evinces  a  tendency  to  talkativeness ;  he  is  always 
busily  engaged  with  his  delusions.  Sometimes  the  delirium  is 
more  violent.  The  victim  is  terror-stricken  by  hideous  illusions 
and  hallucinations.  The  figures  of  the  wall-paper,  and  articles 
of  furniture  are  converted  into  crawling  reptiles  ;  attendants, 
into  demons.  The  patient  is  unable  to  sleep.  Hypnotics  may 
prove  futile.  There  is  little  desire  for  food.  That  wiiich  is 
taken  may  be  rejected.  If  recovery  is  to  take  place,  sleep  is 
gradually  restored  ;  else  the  patient  is  worn  out  and  succumbs 
to  exhaustion.  Pneumonia,  especially  of  the  apices,  is  not  an 
uncommon  complication  of  alcoholism.  The  use  of  tobacco 
during  convalescence  is  sufficient  to  renew  the  attack. 

How  is  delirium  tremens   to   be   distinguished   from  acute 
mania  ? 

The  delirium  of  alcoholic  intoxication  may  be  maniacal,  but 
it  is  associated  with  a  histor}-  of  alcoholism,  w  bile  acute  mania 
usually  develops  in  a  person  with  a  psychopathic  family  history, 
and  has  probahlj'  been  preceded  hy  a  prodromal  period  charac- 
terized by  a  change  in  manner,  in  disposition  or  in  behavior. 
The  character  of  the  illusions  and  hallucinations  difiers  in  the 
two  disorders.  Delirium  tremens  usually  subsides  after  sound 
sleep  for  a  number  of  hours  consecutivel}^  and  recovery  is 
complete.  Evidences  of  insanity  persist  after  the  attack  of 
acute  mania  is  at  an  end. 

How  are  delirium  tremens  and  cerebral  meningitis  to  be  differ- 
entiated ? 
The  distinction  between  delirium  tremens  and  cerebral  men- 
ingitis depends  upon  a  knowledge  of  the  cause,  the  history,  the 


364  ESSENTIALS    OF    DIAGNOSIS. 

course,  the  symptoms  and  the  termination  of  the  two  affections 
respectively.  Delirium  tremens  is  preceded  by  a  history  of  alco- 
holism ;  meningitis,  by  a  history  of  traumatism  or  infection. 
Delirium  tremens  lasts  from  a  few  days  to  a  week  ;  meningitis 
for  a  much  longer  time.  In  meningitis  there  are,  and  in  deli- 
rium tremens  there  are  not,  muscular  spasm,  convulsions  and 
sensory  disturbance,  followed  by  paralysis.  The  delirium  and 
tremor  of  alcoholism  are  peculiar  and  characteristic.  The  tem- 
perature may  be  slightly  elevated  above  the  normal  in  delirium 
tremens,  but  meningitis  is  distinctly  a  febrile  disease. 


Plumbism. 

What  are  the  clinical  manifestations  of  lead-poisoning? 

Lead  may  gain  entrance  into  the  system  and  give  rise  to 
toxic  manifestations  under  diverse  circumstances.  Thus  satur- 
nine intoxication  occurs  in  those  who  work  with  the  metal,  as 
miners,  color-grinders,  painters,  plumbers,  type-founders,  com- 
positors. Lead  may  also  be  introduced  into  the  system  by 
means  of  drinking-water  conveyed  through  lead-pipes,  or  with 
food  prepared  in  leaden  vessels,  or  otherwise  adulterated,  or  by 
the  use  of  hair-dyes,  of  cosmetics,  or  of  snuff  packed  in  lead- 
paper,  or  by  the  medicinal  administration  of  lead  in  some  form. 
Next  to  colic,  the  most  common  manifestation  of  plumbism  is 
multiple  neuritis. 

The  symptoms  vary  in  kind,  degree,  distribution  and  acute- 
ness.  The  more  common  and  the  more  characteristic  are  obsti- 
nate constipation,  abdominal  colic,  wrist-drop,  and  a  blue  line 
on  the  gums.  In  addition,  the  nutrition  is  impaired  and  there 
is  anemia.  Among  other  symptoms  are  cramps  in  the  legs, 
tremor,  headache,  convulsions,  delirium  and  coma.  The  par- 
alysis of  the  extensors  of  the  wrist  and  fingers  upon  which  the 
wrist-drop  depends  is  bilateral,  but  does  not  involve  the  supi- 
nator longus.  Sometimes  the  scapulo-humeral  muscles  are 
affected;  sometimes  the  intrinsic  muscles  of  the  hand  atrophy; 
at  times,  too,  the  lower  extremities  are  paralyzed.  The  knee- 
jerks  may  be  enfeebled  or  lost;  station  may  be  unsteady;  coor- 


PLUMBISM, 


365 


dination  may  be  deranged.  Occasionally,  symptoms  of  sensory 
derangement,  laryngeal  palsy,  mental  fjiilure,  melancholia,  in- 
equality of  the  pupils  and  impairment  of  vision  are  observed. 
Hysterical  symptoms  also  have  been  noted.  The  pupils  may 
be  small  and  fail  to  react  to  light.    The  optic  nerve  may  undergo 


Wrist-drop  from  lead  poisoning.     (Gowers.) 

atrophy.  Paralj^zed  muscles  display  the  reaction  of  degenera- 
tion. Cardio-vascular-renal  changes  are  of  strikingly  common 
occurrence.  Arthritic  manifestations  and  deposits  indistinguish- 
able from  those  of  gout  are  not  rare.  If  potassium  iodid  be  ad- 
ministered, the  urine  may  respond  to  chemic  tests  for  lead. 

How  may  lead- poisoning'  be  confounded  with  cerebral  tumor, 
and  how  is  the  differentiation  to  be  made  ? 

When  the  system  has  been  impregnated  with  lead,  there  may 
be  optic  neuritis,  headache,  convulsions,  delirium  and  palsy  ; 
but  there  are  also  a  blue  line  on  the  gums  ;  a  history  of  expo- 
sure to  the  toxic  metal ;  of  intestinal  colic  ;  of  obstinate  con- 
stipation ;  and  the  palsy  gives  rise  to  wrist-drop. 


366  ESSENTIALS    OF    DIAGNOSIS. 

Torticollis, 

What  is  torticollis  ? 

Torticollis  or  wry-neck  is  a  condition  in  which,  from  shortening 
or  from  spasm  of  one  or  more  muscles  of  the  neck,  the  head  is 
maintained  in  an  abnormal  position. 

What  are  the  varieties  of  torticollis  ? 

There  are  two  types  of  wry-neck.  In  one,  as  a  result  of 
traumatism,  or  of  defective  development,  the  muscle,  usually 
the  sterno-mastoid  upon  one  side,  is  atrophied  and  shortened. 

The  head  is  rotated  to  the  side  opposite  to  that  of  the  affected 
muscle,  which  is  conspicuous  for  its  prominence.  In  the  second 
variety  of  wry -neck,  the  muscles  involved,  most  commonly  the 
sterno-mastoid,  the  trapezius  and  the  splenius,  are  in  a  state  of 
active  contraction,  tonic  or  clonic,  or  alternately  both.  As  a 
result,  the  head  may  be  rotated  or  inclined  to  one  side  or 
retracted  in  over-extension,  in  accordance  with  the  muscle  or 
combination  of  muscles  that  participates  in  the  spasm.  I^ot 
infrequently,  with  the  spasm  of  the  muscles  of  the  neck  is  also 
associated  spasm  of  muscles  of  the  arm  or  of  the  face. 

Occupation-Neuroses. 

What  are  the  occupation-neuroses  ? 

As  the  result  of  persistent  and  long-continued  movement  of 
a  part  in  a  constrained  position,  involving  the  activity  of  certain 
groups  of  muscles,  spasmodic  interference  with  the  performance 
of  the  same  movement  may  develop. 

Thus,  as  a  type  of  the  disease,  there  is  produced  writers' 
cramp  or  scriveners'  palsyo  An  analogous  condition  may  be 
produced  in  telegraphers,  shoemakers,  piano-players,  violinists, 
zither-players,  seamstresses,  smiths,  painters,  turners,  watch- 
makers, knitters,  engravers,  masons,  compositors,  cigarette- 
makers,  milkers,  money-counters,  typewriters,  niotormen,  and 
others. 


WRITERS      CRAMP  —  CHOREA, 


367 


Writers'  Cramp. 

What  are  the  symptoms  of  writers'  cramp  ? 

lu  those  who  write  much,  especially  in  such  a  way  that  the 
burden  of  the  work  falls  upon  the  small  muscles  concerned,  there 
sometimes  develops  a  condition  that  renders  writing  impossible. 
Under  such  circumstances,  as  soon  as  an  attempt  to  write  is 
made,  the  fingers  contract  in  spasm  that  may  be  painful,  so 
that  the  act,  if  possible,  is  imperfectly  accomplished.  At 
other  times,  there  ma}^  be  tremor,  and  rarely  weakness.  In 
some  cases,  neuralgic  pain  is  the  most  conspicuous  symptom. 
Sometimes  vaso-motor  manifestations  are  present,  such  as  local 
heat,  discoloration,  glossiness  of  skin,  undue  sweating.  There 
may  be  slight  muscular  wasting  and  changes  in  electric  reactions. 
In  aggravated  cases  the  manifestations  are  not  confined  to  the 

Fig.  53. 


Mode  of  holding  the  pen  favorable  to 
the  development  of  writers'  cramp. 
(Gowers.) 


Mode  of  holding  the  pen  Tvhen  writ- 
ing becomes  difficult.     (Gowers.) 


act  of  writing,  but  may  appear  upon  attempts  to  perform  other 
movements.  The  onset  of  the  symptoms  is  usually  gradual, 
but  occasionally  it  is  sudden. 


Chorea. 

What  are  the  etiologic  elements  concerned  in  the  determination 
of  an  attack  of  chorea  ? 
Chorea  is  most  common  at  or  about  the  age  of  puberty,  and 


368  ESSENTIALS    OF    DIAGNOSIS. 

more  so  in  girls  than  in  bo3's.  At  Philadelphia,  attacks  are  said 
to  be  more  common  in  the  spring  of  the  year  than  at  any  otlier 
time.  It  has  been  observed  that  chorea  is  more  common  in 
white  than  in  colored  children.  In  many  cases,  an  hereditary 
intluence  can  be  traced — directly,  as  chorea,  or,  more  commonly, 
in  the  nature  of  other  diseases  of  the  nervous  system,  as 
epilepsy  or  insanity,  or  of  rheumatism.  Fright  is  frequently  an 
exciting  cause  of  the  disease.  Occasionally  traumatism  has 
preceded  an  attack.  An  obscure  but  well-determined  causal 
relation  exists  between  acute  rheumatism,  heart-disease  and 
pregnancy,  on  the  one  hand,  and  chorea  on  the  other. 

What  are  the  symptoms  of  chorea  ? 

Chorea  is  a  spasmodic  neurosis,  manifested  by  irregular,  in- 
voluntary, incoordinated  muscular  movements,  aggravated  hj 
excitement  or  observation.  The  movements  cease  during 
sleep,  but  they  may  be  sufficiently  violent  to  prevent  sleep. 
They  are  often  more  decided  on  one  side  of  the  body  than  on 
the  other.  Speech  is  often  interfered  witho  A  slight  degree 
of  muscular  weakness  exists.  The  electric  irritability  is  usually 
increased ;  sometimes  there  are  slight  qualitative  changes. 
Occasionally  pain  is  felt  in  the  parts  affected.  The  tempera- 
ture is,  as  a  rule,  slightly  elevated.  There  is  mental  irritability 
or  dulness  of  intellect.     Anemia  is  often  present. 

At  times,  hemic  heart-murmurs  are  heard  ;  at  other  times, 
murmurs  dependent  upon  organic  disease,  either  antecedent  or 
coincident,  are  heard  ;  endocarditis  is  not  an  uncommon  com- 
plication of  chorea. 

Chorea  is  a  self-limited  affection,  the  average  duration  of 
which  is  about  ten  weeks.  It  is  said  sometimes  to  involve  the 
diaphragm,  and  to  give  rise  to  obstinate  hiccough.  It  is  thought 
that  the  irregularity  of  the  action  of  the  heart,  sometimes  ob- 
served in  choreic  children,  is  dependent  upon  involvement  of  the 
cardiac  muscle  ;  chorea  of  the  larynx  has  also  been  seen. 

So-called  choreoid  movement,  athetosis,  and  mobile  spasm,  are 
often  observed  in  cases  of  paralysis  of  cerebral  origin. 


HEREDITARY    CHOREA SPASMODIC    TIC.  369 


Hereditary  Chorea. 

What  is  hereditary  chorea  or  Huntingdon's  chorea  ? 

A  disorder  resembling  chorea  sometimes  appears  in  families, 
developing  at  the  middle  period  of  life,  and  possibly  continuing 
until  death,  in  hastening  which  it  may  play  some  part.  It  is 
attended  with  irregular,  incoordinate  movements  in  the  hands 
and  ftice.  Speech  is  slow,  difficult,  and  indistinct,  and  the  gait 
is  somewhat  staggering.  Evidences  of  mental  impairment  are, 
however,  often  present,  and  after  death  degenerative  changes 
have  been  found  in  the  cerebral  cortex. 


Spasmodic  Tic. 

What  is  spasmodic  tic  ? 

Spasmodic  tic,  habit-spasm  or  habit-chorea,  is  a  disorder  charac- 
terized by  twitching  or  jerking  of  one  or  more  muscles  or  groups 
of  muscles,  and  manifested  by  blinking  of  the  eyes,  facial  grim- 
aces, shrugging  of  the  shoulders,  sniffing  of  the  nose  and  the 
like.  The  movements  may  disappear  from  one  part  to  appear  in 
another.  The  condition  may  arise  from,  local  irritation,  as  from 
eye-strain  or  ocular  or  nasal  disease,  or  as  a  result  of  imitation. 
It  may  also  attend  trigeminal  neuralgia.  It  is  sometimes  asso- 
ciated with  explosive  utterances. 

How  are  chorea  and  spasmodic  tic  to  be  differentiated  ? 

The  two  affections  differ,  first  of  all,  in  etiology.  Then  the 
movements  in  each  differ  in  character.  In  chorea  they  are  in- 
coordinate and  purposeless,  and  widely  distributed,  being  gen- 
eral or  confined  to  one-half  of  the  body.  The  movements  of 
spasmodic  tic,  on  the  other  hand,  are  apparently  purposive  and, 
as  a  rule,  less  widely  distributed;  further,  they  vary  from  time 
to  time,  one  set  alternating  with  another.  Spasmodic  tic  is 
usually  the  more  protracted  disorder,  sometimes  lasting  for 
years,  and  it  yields  less  readily  to  treatment,  especially  to 
arsenic. 

24 


370  ESSENTIALS    OP    DIAGNOSIS. 

Epilepsy. 

What  is  the  etiology  of  epilepsy  ? 

Ejnlepsyis  immediately  dependent  upon  an  irritable  condition 
of  the  nervous  system  that  must  be  referred  to  changes  in  the 
nerve-cells,  beyond  our  present  means  of  recognition.  The 
disease  is  more  common  in  females  than  in  males.  In  a  con- 
siderable proportion,  a  neurotic  heredity  can  be  traced.  In 
many  cases,  no  etiologic  factor  can  be  determined.  The  first 
attack  usually  occurs  in  early  life,  frequently  in  conjunction 
with  dentition,  or  in  association  with  rachitis.  In  other  cases,  it 
may  be  excited  by  mental  influences,  especially  anxiety,  by  fails 
or  blows,  by  acute  disease,  by  the  presence  of  parasites  in  the  in- 
testine, by  menstrual  derangement,  by  nasal  polypi,  by  phimosis, 
by  cicatrices,  and  by  other  sources  of  peripheral  irritation. 

When  no  source  of  irritation,  direct  or  reflex,  can  be  found, 
the  disease  is  designated  essential  or  idiopailiic. 

What  are  the  symptoms  of  epilepsy  ? 

Epilepsy  is  a  paroxysmal  neurosis,  characterized  by  attacks 
of  varying  frequency,  duration  and  severity,  which  ma}^  ap- 
pear as  transient  loss  of  consciousness  [petit  mal.  minor  epilepisy) 
or  may  be  preceded  by  a  premonitory  sensation  or  aura,  fol- 
lowed successively  by  a  cry,  loss  of  consciousness,  frothing  at 
the  mouth,  tonic  followed  by  clonic  convulsions,  headache, 
biting  of  the  tongue  and  somnolence  [grand  mal^  major  epilepsy). 

The  attacks  of  petit  mal  may  be  so  inconspicuous  as  to 
escape  observation.  There  may  be  simply  a  vertiginous  or 
other  abnormal  sensation,  or  an  abrupt  interruption  in  speech  ; 
or  the  grasp  of  an  object  held  in  the  hand  may  be  relaxed  ;  or 
there  may  be  a  twitching  of  the  muscles  of  the  face. 

When  the  seizure  is  preceded  by  an  aura,  this  may  be 
motor,  sensory,  visceral  or  psychic.  In  the  attack  the  face 
l}ecomes  at  first  pallid,  then  flushed,  and  finally  cj^anotic  ;  the 
pupil  is  dilated  and  insensible  to  light ;  urine  and  feces  may  be 
expelled  involuntarily.  The  urine  may  contain  a  trace  of 
albumin. 

Mental  deterioration  ensues  in  a  degree  corresponding  to  the 


EPILEPSY.  371 

frequency  of  the  attacks.  Paroxysms  may  be  succeecled  by 
transient  hemiplegia  and  aphasia,  by  the  automatic  performance 
of  some  act  or  by  mania. 

Sometimes  a  series  of  convulsions  occurs,  one  attack  scarcely 
ceasing  before  another  begins,  constituting  the  status  ejAkpticus. 

Nothing  is  known  of  the  pathologic  anatomy  of  epilepsy. 

How  are  the  epileptiform  convulsions  of  cerebral  disease  to  be 

distinguished  from  attacks  of  true  epilepsy  ? 
Epileptiform  convulsions  usually  result  from  lesions  involving 
the  cortex  cerebri.  The  most  common  of  these  lesions  are 
softening  from  vascular  occlusion,  hemorrhage  and  new- 
growths.  The  convulsions  occasioned  are  likely  to  be  local  in 
character  and  not  at  the  onset  attended  with  loss  of  conscious- 
ness ;  while  the  convulsions  of  epilepsy  are  usually  general  and 
simultaneous  with  loss  of  consciousness.  In  the  intervals  be- 
tween epileptiform  convulsions,  some  evidences  of  cerebral 
disease — hemiplegia,  athetoid  movements,  choked  discs — are 
likely  to  be  present. 

What  are  the  distinctions  between  chorea  and  epilepsy  ? 

Epilepsy  occurs  in  paroxysms  with  intermissions,  and  may 
persist  during  the  greater  part  of  life  ;  chorea  is  but  a  temporary, 
self-limited  condition,  the  sjauptoms  of  which  are  constant 
during  the  continuance  of  the  disease.  The  movements  of 
chorea  do  not  possess  the  violence  of  the  convulsions  of  epilepsy  ; 
nor  in  chorea  is  consciousness  lost  or  the  tongue  bitten. 

How  are  the  attacks  of  syncope  and  those  of  petit  mal  to  be 
differentiated  ? 
Syncope  occurs  under  well-known  circumstances  that  occasion 
temporary  cerebral  jinemia  ;  the  pulse  at  the  wrist  is  almost 
obliterated;  loss  of  consciousness  is  of  brief  duration;  the 
return  to  the  normal  condition  takes  place  slowl}^  In  case  of 
petit  mal,  there  have  been  previous  attacks  of  a  similar  character 
or  perhaps  of  major  epilepsy  ;  the  loss  of  consciousness  is  sudden 
and  transitory  ;  the  normal  condition  is  soon  resumed  ;  there  may 
have  been  slight  muscular  t witch ings  ;  or  urine  may  have  been 
passed  involuntarily  ;  or  some  automatic  action  is  performed. 


372  ESSENTIzVLS    OF    DIAGNOSIS. 

How  is  eclampsia  to  be  disting:uished  from  epilepsy  ? 

By  eclampsia  is  meant  convulsions  occurring  incidentally  and 
temporarily,  as  during  dentition,  or  in  connection  with  preg- 
nancy and  parturition.  The  relation  of  eclampsia  to  epilepsy 
and  epileptiform  convulsions  is  uncertain.  The  recognition  of 
eclampsia  and  its  distinction  from  epilepsy  and  epileptiform 
convulsions  depend  upon  its  incidental  and  transient  occurrence 
in  connection  with  one  of  the  conditions  that  give  rise  to  it. 

How  are  the  convulsions  of  uremia  and  those  of  epilepsy  to  be 
differentiated  ? 

The  convulsions  of  uremia  are  not  unlike  those  of  epilepsy. 
Their  significance,  however,  depends  upon  their  association 
with  edema,  a  peculiar  mustiness  of  the  breath,  the  presence  of 
albumin  and  tube-casts  in  the  urine,  and  the  existence  of  degen- 
erative changes  in  the  retina.  If  obtainable,  the  previous  his- 
tory may  determine  the  diagnosis. 

Hysteria. 

What  are  the  symptoms  of  hysteria  ? 

Hysteria  is  a  disease  of  the  nervous  system,  more  common  in 
females  than  in  males,  and  in  early  adult  life  than  at  any  other 
period.  In  many  cases  a  neuropathic  heredity  can  be  traced. 
The  manifestations  of  the  disease  may  be  induced  by  mental 
emotion,  anxiety,  visceral  disease  and  other  disease.  As  a  rule, 
they  are  sudden  in  onset  and  as  sudden  in  disappearance.  They 
may  be  dissipated  by  a  profound  mental  impression.  The  symp- 
toms are  protean  ;  some  are  continuous,  others  paroxysmal. 
Among  the  former  are  derangements  of  sensibility  and  motility, 
visceral,  vaso-motor  and  cerebral  disturbances  ;  the  paroxysmal 
symptoms  include  convulsive  seizures.  That  which  fundament- 
ally characterizes  the  disease  is  a  loss  of  self-control,  a  deficiency 
of  will-power,  a  heightened  self-consciousness,  a  tendency  to 
exaggeration  and  a  morbid  desire  for  sympathy.  The  patient  is 
moved  to  laughter  or  tears  with  undue  readiness  and  without 
adequate  cause.  Duplicity  and  deception  are  practised,  and 
there  is  an  irresistible  tendency  to  imitation.     Sensation  may 


HYSTERIA.  373 

be  lost  or  heightened,  or  otherwise  abnormal,  locally-,  or  upon 
one-half  of  the  bod}^,  or  in  irregular  distribution,  with  un- 
steady station  and  gait  when  the  eyes  are  closed.  Spinal 
tenderness  is  common.  There  is  frequently  a  recurrent  sen- 
sation of  obstruction  in  the  throat,  as  of  a  ball  rising  from 
the  stomach,  or  of  a  sense  of  pharyngeal  constriction — the 
so-called  glohiis  hystericus.  At  times,  there  is  a  feeling  of 
intense  pain  in  the  head,  such  as  might  be  occasioned  by  the 
driving  in  of  a  nail— the  davus  hystericus.  The  special  senses 
may  be  variousl}'  impaired.  Motor  palsy  of  diverse  distribution 
may  exist,  occasioning  paraplegia,  hemiplegia  or  monoplegia, 
unattended  with  muscular  wasting  or  alteration  in  the  elec- 
tric reactions  or  impairment  of  activity  of  the  sphincters. 
Sometimes  there  is  inability  to  stand  or  to  sit — astasia-cibasia. 
The  reflexes  are  usually  unaltered  :  in  a  number  of  cases,  they 
are  exaggerated.  There  may  be  aphonia,  loss  of  the  power  of 
articulation,  retention  of  urine,  constipation,  stammering. 
Contractures  may  take  place  and  give  rise  to  troublesome 
deformit}-.  Laryngeal  spasm  may  occasion  distressing  dyspnea, 
or  a  peculiar  barking  cough.  Independently  of  any  spasm,  there 
may  be  increased  frequency  of  respiration,  with  shortness  of 
breath.  Spasm  of  the  pharynx  or  of  the  esophagus  may  entail 
the  rejection  of  all  food  ingested.  There  may  in  addition  be 
such,  repugnance  to  food  that  little  is  taken.  On  the  other  hand, 
the  appetite  may  be  strangely,  even  disgustingly  peiwerted. 
There  may  be  local  flushing  and  perspiration.  In  females, 
menstruation  may  be  deranged  ;  ovarian  tenderness  is  common. 
The  paroxysmal  attacks  of  convulsions  are  marked  b}'  tonic  and 
clonic  spasm,  without  loss  of  consciousness  or  biting  of  the  tongue. 
The  arms  and  legs  are  wildly  thrown  about  by  coordinated  mus- 
cular activity — purposive  movement.  The  patient  may  shriek 
and  bite  the  lips.  Opisthotonos  and  trismus  may  be  developed. 
At  times,  there  are  evidences  of  profound  psychic  disturbance, 
as  manifested  by  hallucinations  and  delusions,  perhaps  of  an 
erotic  nature.  Lethargy  and  catalepsy  are  sometimes  observed. 
The  temperature  may  display  decided  irregularity. 


374  ESSENTIALS    OF    DIAGNOSIS. 

How  are  hysterical  paralysis  and  the  cerebral  paralysis  of 
organic  origin  to  be  differentiated  ? 

The  palsy  of  hysteria,  hemiplegic,  paraplegic,  diplegic  or 
monoplegic,  is  usually  atypical. 

The  face  is  rarely  involved.  Sensory  derangement  is  common. 
The  evidences  of  secondary  descending  degeneration  :  contrac- 
tures and  exaggeration  of  reflexes  may  be  wanting.  There  may 
be  constipation  and  retention  of  urine,  but  not  incontinence. 

Wliile  the  onset  may  have  been  sudden,  it  will  not  have  been 
apoplectic.  Other  S3anptoms  of  hysteria  may  make  the  character 
of  the  palsy  clear,  but  the  mere  existence  of  the  symptoms  of 
hysteria  should  not  obscure  the  possible  simultaneous  existence 
of  organic  disease. 

How  are  the  convulsions  of  hysteria  and  those  of  epilepsy  to 
be  differentiated  ? 

An  ej^ileptic  paroxysm  takes  place  without  special  excitation, 
and  sets  in  abruptly,  often  with  a  cry  ;  an  hysterical  attack  may 
be  brought  on  by  emotion,  sets  in  gradually,  and  is  attended 
with  screaming.  The  convulsions  of  epilepsy  pursue  a  regular 
sequence,  and  are  associated  with  cyanosis,  biting  of  the  tongue, 
and  insensibility  of  the  iris  to  light ;  in  the  hysterical  attack,  the 
members  are  wildly  thrown  about,  the  pupil  responds  to  stimu- 
lation, while  the  patient  may  bite  the  lips  or  hands  or  other 
persons  or  things.  Involuntary  extrusion  of  urine  and  feces 
may  tal?:e  place  in  epilepsy  ;  but  does  not  occur  in  hysteria. 

Loss  of  consciousness  is  complete  in  epilepsy  ;  consciousness 
is  retained  or  perverted  in  hysteria,  the  paroxysm  of  which  is 
characterized  by  talkativeness. 

The  epileptic  attack  lasts  but  a  few  minutes  ;  the  hysterical, 
ten  minutes  or  longer.  Opisthotonos  is  common  in  hysteria, 
exceptional  in  epilepsy. 

An  epileptic  seizure  may  occur  at  any  time  and  under  any 
circumstances  ;  hysterical  attacks  take  place  only  in  the  presence 
of  a  second  iDerson.  The  hysterical  patient  is  careful  in  the 
paroxysm  to  suffer  no  injury  ;  the  epileptic  falls,  whatever  the 
attendant  dangers,  powerless  to  avert  them. 

An  hysterical  patient  may,  however,  also  be  epileptic. 


NEURASTHENIA.  375 

What  are  the  distinctions  between  spastic  paraplegia  and 
hysterical  paraplegia? 

Spastic  paraplegia  develops  at  an  age  when  hysteria  is  com- 
mon ;  but  in  hysteria  the  reflexes  may  not  be  exaggerated  and 
the  peculiar  muscular  spasm  of  lateral  sclerosis  does  not  occur, 
while  sensory  and  emotional  symptoms  cannot  escape  ob- 
servation. 

How  are  acute  myelitis  and  hysterical  paraplegia  to  be  differ- 
entiated ? 

Myelitis  should  not  be  overlooked  because  it  occurs  under  cir- 
cumstances amid  which  hysteria  is  to  be  expected.  Exaggerated 
reflexes,  trophic  changes,  wasting,  derangement  of  sphincters 
and  girdle-pain  indicate  the  existence  of  more  than  hysteria. 

How  are  the  symptoms  of  hysteria  and  those  of  meningitis  to 
be  differentiated  ? 
If  symptoms  of  meningitis  appear  in  an  hysterical  individual, 
their  true  significance  may  be  overlooked.  Convergent  strabis- 
mus may  be  hysterical ;  but  divergent  strabismus  always 
depends  upon  organic  disease.  There  may  be  retention  of  urine 
in  hysteria,  but  there  is  never  incontinence.  Trophic  changes 
and  continued  elevation  of  temperature  are  evidences  of  the 
existence  of  something  more  than  functional  disease. 

How  are  hysteria  and  cerebral  tumor  to  be  differentiated  ? 

Hysteria  may  present  any  of  the  imitable  symptoms  of  cere- 
bral tumor,  but  in  addition  there  will  always  be  indubitable 
evidence  of  their  nature.  Optic  neuritis  or  ptosis,  of  course, 
is  not  to  be  duplicated.  Hysterical  manifestations  in  associa- 
tion with  cerebral  symptoms  should  not  be  permitted  to  obscure 
the  existence  of  organic  disease. 


Neurasthenia. 

What  is  neurasthenia  ? 

Neurasthenia  is  a  condition  characterized  by  undue  readiness 
of  fatigue  from  ordinary  mental  or  physical  activity,  with  en- 
feebled power  of  recuperation,  probably  dependent  upon  nu- 


376  ESSENTIALS    OF    DIAGNOSIS. 

tritive  disturbance  of  the  nervous  system  and  manifested  by 
irritable  weakness. 

What  are  the  causes  of  neurasthenia  ? 

Neurasthenia  is  more  common  in  women  than  in  men,  and 
during  active  adult  life  than  at  any  other  period.  The  predis- 
position is  transmitted  by  heredity.  The  disorder  is  super- 
induced by  overwork,  with  inadequate  rest,  by  worry,  anxiety, 
grief,  mental  shock,  or  other  emotional  disturbance,  by  exces- 
sive use  of  tea,  coffee,  tobacco,  and  alcohol,  by  drug-addiction, 
by  sexual  excesses,  by  traumatism,  by  protracted  lactation,  by 
w^asting  discharges,  by  debilitating  diseases,  by  impaired  nutri- 
tion from  whatever  cause. 

What  are  the  symptoms  of  neurasthenia  1 

Among  the  most  common  clinical  manifestations  of  neuras- 
thenia are  a  sense  of  tire  or  fatigue,  spontaneous  or  readily 
induced,  with  indisposition  to  activity ;  a  feeling  of  distress  in 
the  head,  or  of  fulness,  or  of  weight  or  pressure ;  noises  in  the 
ears,  especially  in  the  recumbent  posture  ;  disturbed  and  unre- 
freshing  sleep  at  night,  with  perhaps  undue  drowsiness  by  day, 
tremulousness  or  agitation  or  fright  on  slight  or  on  no  provoca- 
tion;  morbid  fears  of  all  kind;  mental  depression,  with  a  ten- 
dency to  weep;  irritability  of  temper;  pain  in  the  back  and 
elsewhere.  The  reflexes  are  often  sensitive  and  irritable,  and 
station  uncertain.  Digestion  is  commonly  impaired  and  con- 
stipation is  the  rule,  though  sometimes  the  bowels  are  loose. 
There  may  be  increased  frequency  of  micturition,  but,  as  a  rule, 
the  urine  is  not  increased  in  amount,  nor  does  it  contain  ab- 
normal ingredients.  In  women  menstruation  is  likely  to  be 
deranged  and  flushing  is  complained  of.  Palpitation  of  the 
heart  may  be  present,  together  with  pulsation  of  the  aorta  and 
a  sense  of  beating  in  various  situations. 

How  are  hysteria  and  neurasthenia  to  be  dififerentiated  ? 

The  one  is  a  psycho-neurosis  characterized  especially  by  want 
of  functional  coordination  and  attended  by  varied  disturbances 
of  cerebro-spinal  activity  and  of  motility  and  general  and  special 
sensibility ;  the  other  is  essentially  a  condition  of  irritable  weak- 
ness, a  fatigue  psycho-neurosis,  and  wanting  in  the  character- 


FAMILY    PERIODIC    PARALYSIS  —  TETANUS.       377 

istic  motor,  sensoiy  and  psychic  phenomena  of  the  former. 
Hysteria  is  often  of  abrupt  origin,  due  to  a  powerful  cause,  and 
terminating  abruptly ;  while  neurasthenia,  as  a  rule,  is  due  to  a 
long-acting  cause  and  of  gradual  development  and  decline.  The 
symptoms  of  hysteria  are  often  local  in  distribution ;  those  of 
neurasthenia  usually  general.  Both  diseases  may  be  present  in 
the  same  individual. 

Family  Periodic  Paralysis. 

What  is  family  periodic  paralysis  ? 

Under  tliis  name  there  has  been  described  a  form  of  flaccid 
motor  palsy,  of  varying  degree  and  distribution,  with  loss  of 
reflexes  and  electric  irritability,  but  without  sensory  derange- 
ment. The  condition  recurs  periodically,  the  patient  being  free 
from  symptoms  in  the  intervals.  In  many  cases  .a  family  history 
of  the  disorder  can  be  elicited. 

Tetanus. 

What  are  the  symptoms  of  tetanus  ? 

Tetanus  is  a  spasmodic  disorder  dependent  upon  a  specific 
bacillus  contained  in  soil  and  introduced  into  the  s^'stem 
through  wounds  or  abrasions.  It  is  manifested  by  painful 
rigidity  of  the  head  and  jaw,  soon  progressing  to  trismus,  and 
by  stiffness  of  the  tongue.  In  turn,  the  rigidity  involves  the 
muscles  of  the  face  (resulting  in  the  rims  sardonicus),  the  mus- 
cles of  the  trunk,  the  respiratory  muscles,  and  the  diaphragm. 
To  the  tonic  spasm  of  the  muscles  are  added  frequently  recur- 
ring clonic  exacerbations,  which  may  be  induced  by  external 
irritation.  Sometimes  there  are  paralysis  of  the  facial  muscles 
and  difficulty  in  swallowing. 

The  body  may  be  arched  in  strong  extension  and  supported 
only  on  the  head  and  heels,  constituting  opisthotonos ;  it  may  be 
strongly  arched  forward  {emprosthotonos),  or  laterally  [pjleuros- 
thotwws),  or  it  may  be  rigicll}^  straight  {orthotonos) .  The  symp- 
toms of  tetanus  set  in  at  a  variable  period  after  inoculation — 
from  a  few  hours  to  several  days.  The  duration  of  the  disease 
likewise  varies  from  a  few  days  to  several  weeks.     Eecovery  is 


378  ESSENTIALS    OF    DIAGNOSIS. 

exceptional.     Towards  the  close  of  life  or  even  after  death,  the 
temperature  may  rise  to  an  extraordinar}'  height. 

How  are  hysterical  trismus  and  opisthotonos  to  be  distinguished 
from  tetanus  ? 
Hysteria  is  an  unruly  disease,  the  symptoms  of  which  are 
disorderly  in  appearance,  while  the  symptoms  of  tetanus  appear 
in  fairly  regular  succession.  Should  trismus  or  opisthotonos 
develop  as  a  manifestation  of  hysteria,  it  is  likely  to  be  asso- 
ciated with  other  symptoms  of  hysteria.  The  paroxysms  remit 
and  recur  and  do  not  go  on  to  a  fatal  termination. 

How  is  strychnine-poisoning  to  be  distinguished  from  tetanus  ? 

Strychnine-poisoning  gives  rise  to  some  of  the  manifestations 
of  tetanus.  If  trismus  develops  in  strychnine-poisoning,  it  does 
so  late  ;  in  tetanus,  it  is  one  of  the  first  symptoms. 

The  convulsions  of  strychnine-poisoning  are  intermittent,  but 
may  be  induced  by  external  irritation  ;  those  of  tetanus  are 
continuous,  with  paroxysmal  exacerbations ;  inquiry  into  the 
history  of  the  case  may  elicit  important  evidence. 

How  are  hemorrhage  into  the  spinal  membranes  and  tetanus 
to  be  differentiated  ? 

Meningeal  hemorrhage  is  sudden,  tetanus  gradual,  in  onset. 
Pain  is  a  more  prominent  symptom  in  hemorrhage  than  in 
tetanus.  Trismus  is  wanting  in  hemorrhage  ;  it  is  characteristic 
of  tetanus.  Spasm  is  constant  in  tetanus,  with  exacerbations  ; 
intermittent  in  meningeal  hemorrhage. 

How  are  acute  spinal  meningitis  and  tetanus  to  be  differ- 
entiated ? 

Meningitis  sets  in  abruptly  with  a  chill,  followed  by  elevation 
of  temperature  ;  tetanus  is  of  gradual  development,  usually 
after  an  injury,  and  is  at  the  outset  unattended  with  elevation 
of  temperature.  Trismus  is  characteristic  of  tetanus,  but  ex- 
ceptional in  meningitis. 

The  convulsions  of  tetanus  are  excited  by  slight  peripheral 
irritation  ;  the  muscular  contractions  of  meningitis  are  induced 
by  efforts  at  movement. 

Tetanus  is  far  more  commonly  fatal  than  is  meningitis.  Motor 
and  sensory  impairment  are  common  sequelae  of  meningitis. 


TETANY.  379 


Tetany. 

What  is  the  etiology  of  tetany  ? 

Tetany  is  most  coiiiinon  in  infancy  and  early  adult  life,  when 
males  are  more  prone  to  the  disease  than  females.  Occurring 
later  in  life,  females  are  aftected  in  larger  proportion.  In  some 
cases,  an  hereditar}'-  influence  can  be  made  out.  In  many, 
diarrhea  is  an  exciting  cause.  In  others,  the  affection  has  been 
preceded  by  one  of  the  acute  infectious  diseases.  Pregnant  or 
nursing  women  seem  especially  predisposed.  The  disease  has 
been  observed  to  develop  in  a  considerable  number  of  cases  fol- 
lowing removal  of  the  thj^roid  gland.  It  has  also  been  seen  in 
association  with  dilatation  of  the  stomach.  In  children  it  is 
often  associated  with  rachitis,  laryngismus  stridulus,  carpo-pedal 
spasm  and  convulsions.  Other  possible  causes  are  exposure  to 
cold  and  blows  and  injuries.  Epidemics  of  the  disease  have 
been  observed. 

What  are  the  symptoms  of  tetany  ? 

Tetany  is  an  affection  characterized  by  muscular  spasm,  of 
symmetrical  distribution,  which  usually  begins  and  is  most 
marked  in  the  extremities. 

The  spasm  may  be  continuous,  remittent  or  intermittent. 

A  paroxysm  may  be  induced  by  compression  of  the  vessels 
and  nerves  of  a  part. 

At  the  onset  of  the  attack,  there  may  be  headache,  vomiting, 
spinal  pain,  numbness  and  tingling.  There  may  be  moderate 
elevation  of  temperature. 

In  the  intervals  between  paroxysms,  the  mechanical  excita- 
bihty  and  electric  irritability  of  nerve  and  muscle  are  height- 
ened. The  disease  may  continue  for  a  period  ranging  from  a 
few  days  to  several  months. 

Cases  in  which  the  spasm  is  intermittent  are  longer  in  dura- 
tion than  those  in  which  the  spasm  is  continuous. 

How  are  tetany  and  tetanus  to  be  distinguished  ? 

The  spasm  of  tetany  is  more  likely  than  that  of  tetanus  to 
be  intermittent.     Trismus  is  an  early  symptom  of  tetanus  ;  if 


380  ESSENTIALS    OF    DIAGNOSIS. 

it  occurs  at  all  in  tetany,  it  appears  late.     The  participation  of 
the  extremities  in  the  spasm  is  a  feature  of  tetany. 

Hydrophobia. 

What  are  the  clinical  features  of  hydrophobia  ? 

Hydvopliohia  results  from  the  inoculation  of  man  with  rabies 
of  animals.  The  infection  is  usually  transmitted  by  the  saliva 
of  a  rabid  beast,  as  a  dog,  a  cat,  a  fox,  or  a  wolf,  through 
a  bite  or  a  preexisting  wound.  The  period  of  incubation  of 
hydrophobia  is  extremely  variable,  but  is  on  an  average  from 
six  to  ten  weeks.  During  this  time,  the  primary  wound  may 
have  healed,  and  no  symptom  have  been  present.  Local 
pain  may  be  perceived  preceding  the  development  of  the  dis- 
ease proper,  with  the  onset  of  which  there  are  a  sense  of 
malaise,  mental  depression  and  slight  difficulty  in  swallowing. 
Sleep  is  impaired  and  there  may  be  respiratory  spasm.  The 
stomach  now  becomes  intolerant,  rejecting  everj^thing  intro- 
duced. The  muscular  spasm  extends  and  cutaneous  hyperes- 
thesia becomes  manifest.  External  stimuli  readily  induce 
convulsions.  The  mental  distress  becomes  intense.  The  tem- 
perature is  elevated.  Priapism  may  occur.  Albumin  and 
sugar  are  sometimes  found  in  the  urine.  Ultimately,  paralytic 
phenomena  may  supervene.  Death  may  result  from  exhaus- 
tion, by  reason  of  the  inability  to  retain  food,  and  the  violence 
of  the  convulsions  ;  from  suffocation,  as  a  result  of  respiratory 
spasm  ;  or  from  heart-failure. 

How  are  lyssophobia  or  pseudo-hydrophobia  and  true  hydro- 
phobia to  be  differentiated? 

Persons  who  have  been  bitten  by  animals,  rabid  or  not, 
develop  a  state  of  fear  and  dread,  sometimes  difficult  to  dis- 
tinguish from  true  hydrophobia.  Usually,  however,  the  laryn- 
geal and  pharyngeal  spasm  characteristic  of  hydrophobia  is 
wanting,  while  judicious  moral  assurance  may  cause  a  dissipa- 
tion of  the  symptoms. 


EXOPHTHALMIC    GOITER.  381 

How  are  hydrophobia  and  tetanus  to  be  differentiated  ? 

Ill  hydrophobia  there  is  the  history  of  a  bite,  with  a  long  period 
of  incubation  ;  in  tetanus  of  wound-infection  with  earth,  and  a 
short  period  of  incubation.  In  hydrophobia,  respiratory  and 
pharyngeal  spasm  is  an  early  manifestation  ;  in  tetanus,  trismus 
is  among  the  tirst  symptoms.  In  the  former  all  food  is  rejected  ; 
in  the  latter,  if  food  can  be  introduced  into  the  mouth,  there  is 
no  difficulty  of  retention.  Tetanus  does  not  present  the  inten- 
sity of  mental  distress  and  disturbance  encountered  in  hydro- 
phobia. 

Aural  Vertigo— Labyrinthine  Vertigo. 

What  is  aural  vertigo  ? 

3Ierdere's  disease,  aural  or  lahyrinthine  vertigo,  is  an  afiection 
dependent  upon  a  pathologic  condition  of  the  terminal  fibers 
of  the  auditory  nerve  in  the  labyrinth.  The  disease  of  the 
labyrinth  may  be  inflammatory,  gouty,  syphilitic  or  degenera- 
tive. The  symptoms  occasioned  are  impairment  of  hearing, 
tinnitus  aurium  and  vertigo.  The  last  is  aggravated  in  parox- 
ysms, in  which  in  addition  there  are  nausea  and  vomiting,  with 
pallor  of  the  face  and  cold  sweats.  The  patient  may  fall  to 
the  ground  and  the  vertigo  be  so  intense  that  he  is  temporarily 
unable  to  arise. 

How  are  epilepsy  and  aural  vertigo  to  be  differentiated  ? 

Epilepsy  is,  and  aural  vertigo  is  not,  attended  with  muscular 
spasms  and  loss  of  consciousness.  In  the  intervals  between 
the  paroxj'sms  of  aural  vertigo  some  degree  of  dizziness  persists 
and  there  are  also  impairment  of  hearing  and  tinnitus  aurium, 
which  are  not  accompaniments  of  ejDileps}-. 

Exophthalmic  Goiter, 

What  are  the  symptoms  of  exophthalmic  goiter  ? 

Exophthalmic  goiter,  also  called  Graves-s  disease  and  Basedow^s 
disease,  is  an  affection  characterized  by  increased  frequency  of 
action  and  palpitation  of  the  heart,  protrusion  of  the  eyeballs, 


382 


ESSENTIALS    OF    DIAGNOSIS 


enlargement  of  the  thyroid  gland  and  tremor.  It  is  clinically  a 
vaso-motor  disorder  of  autotoxic  origin,  and  its  manifestations 
are  probably  dependent  upon  excessive  functional  activity  of 
the  thyroid  gland. 

The  disease  is  more  common  in  females  than  in  males,  and 
in  adult  life  than  at  any  other  period.     In  some  cases  a  neuro- 


FiG.  54. 


Case  of  exophthalmic  goiter.     (Personal  observation.) 

pathic  heredity  can  be  traced.  The  exciting  cause  is  usually 
mental  emotion,  shock,  grief,  or  anxiety.  Traumatism  is  some- 
times the  determining  factor,  and  the  disease  has  developed 
after  operation  followed  by  infection.     By  some  observers  in- 


EXOPHTHALMIC    GOITER.  383 

toxication  from  the  intestinal  tract  is  believed  to  be  a  potent 
cause. 

The  onset  may  be  either  insidious  or  abrujDt,  and  the  course 
gradual  or  rapid. 

Palpitation  of  the  heart,  associated  with  or  independent  of 
an  organic  lesion,  is  one  of  the  earliest  symptoms.  The  action 
of  the  heart  is  increased  both  in  frequency  and  in  energy,  and 
is  often  extremely  irregular.  The  tachycardia  and  the  palpita- 
tion may  reach  a  high  degree  of  intensity,  the  pulse  sometimes 
exceeding  140  in  the  minute.  There  may  also  be  evident  pulsa- 
tion in  the  arteries  and  a  bruit  in  the  vessels  of  the  neck. 

Anemia  is  often  an  early  symptom.  In  the  progress  of  the 
case,  the  eyes  protrude  and  the  thyroid  gland  becomes  enlarged. 

The  exophthalmos  and  the  goiter  may  each  be  symmetrical 
or  unilateral ;  the  protrusion  and  the  enlargement,  respectively, 
are  not  uncommonly  greater  upon  the  right  side.  In  some 
cases,  the  upper  lids  are  retracted,  displaying  the  sclerotic,  and 
do  not  follow  the  eyes  when  the  glance  is  depressed.  Infre- 
quency  of  winking  and  insufficiency  of  convergence  have  been 
observed. 

Over  the  enlarged  thyroid  gland  a  blowing  systolic  bruit  is 
usually  to  be  heard.  The  goiter  frequently  pulsates  ;  it  is  at  first 
usually  elastic  ;  ultimately  it  may  become  tirm.  The  appearance 
of  the  goiter  may  be  intermittent ;  when  permanent,  the  en- 
largement may  undergo  spontaneous  variation. 

Among  other  symptoms  are  nystagmus,  tremor  of  the  ex- 
tremities, dermagraphism,  an  abnormal  sense  of  heat,  flush- 
ing and  perspiration.  It  has  been  stated  that  the  bodily 
electric  resistance  is  diminished.  Various  cutaneous  affections 
have  been  noted.  In  women,  menstruation  is  commonly  de- 
ranged. 

In  some  cases,  albuminuria,  in  others,  diabetes  has  been 
observed.  Hemoptysis,  hematuria,  hematemesis  and  other 
hemorrhages,  and  sometimes  purpura,  occur.  Mental  changes 
are  not  uncommon.     Mania  is  an  occasional  complication. 

Exophthalmic  goiter  has  been  followed  by  myxedema ;  it  is 
not  directly  fatal.  Spontaneous  recession  or  recovery  is  pos- 
sible.   Temporary  exacerbations  take  place. 


384  ESSENTIxVLS    OF    DIAGNOSIS. 

What  are  the   features   distinguishing   exophthalmic  goiter 
from  simple  goiter? 

Occasionally,  the  enlargement  of  the  thyroid  gland  may  be 
the  first  symptom  of  exophthalmic  goiter  observed.  The  bruit 
heard  over  the  gland  in  exophthalmic  goiter  is  wanting  in  the 
simple  enlargement.  Then,  investigation  will  disclose  the  exist- 
ence of  palpitation  and  examination  will  reveal  increased  rapiditj^ 
of  the  action  of  the  heart,  with  the  development,  in  the  progress 
of  the  case,  of  protrusion  of  the  eyes  and  the  other  symptoms 
of  exophthalmic  goiter.  Even  before  the  heart  is  much  dis- 
turbed, there  may  be  a  tendency  to  tiushing  of  the  face,  and  occa- 
sionally red  blood-cells  may  be  found  in  the  urine. 

Vasomotor  Ataxia. 

What  is  vasomotor  ataxia  ? 

In  predisposed  persons,  especially  those  of  neurotic  inheri- 
tance, there  occur  under  various  exciting  influences,  principally 
emotion,  temperature,  weather,  drugs,  and  other  toxic  ingesta 
or  disturbed  metabolism,  and  in  most  women  during  the  climac- 
teric, symptoms  of  deranged  circulation,  spasmodic,  paretic,  or 
mixed.  These  vary  much  in  intensity  from  mere  "flushes  of 
heat"  and  "chilly  sensations,"  urticarious  and  other  eruptions, 
to  hemorrhagic  discharges,  vertigo,  and  transient  blindness, 
tachycardia,  angina,  etc.  Exophthalmic  goiter,  hay -fever,  an- 
gioneurotic edema,  certain  forms  of  asthma  and  renal  leakage, 
and  other  forms  of  n euro-vascular  disorder  may  all  be  exag- 
gerated types  of  this  afli'ection. 

Cretinism. 

What  is  cretinism  ? 

Cretinism  is  a  morbid  condition,  occurring  endemically  or 
sporadically  and  manifested  by  characteristic  mental  and  phj^s- 
ical  abnormalities.  The  body  is  un'dersized  ;  the  head  is  broad, 
but  shallow  ;  the  eyes  are  far  apart  and  the  nose  is  flat ;  the  lips 
are  thick  ;   the  tongue  is  sometimes  enlarged  ;   the  hands  are 


MYXEDEMA.  385 

broad  and  spade-like  ;  the  skin  is  dry,  rough  and  wrinkled  ;  the 
aspect  is  that  of  age  ;  the  hair  is  straight  and  stitT;  the  intelli- 
gence is  feeble,  even  to  the  degree  of  idiocy  ;  masses  of  fat 
sometimes  appear  in  the  posterior  triangles  of  the  neck ;  the 
thyroid  gland  is  often  enlarged  ;  it  is  sometimes  wanting.  In  a 
number  of  cases  premature  ossification  of  the  occipito-sphenoidal 
suture  has  been  found.  Some  members  of  families  in  which 
cretinism  existed  have  presented  goiters.  Tlie  condition  is 
closely  related  to,  if  not  identical  with,  myxedema. 

Myxedema. 

What  are  the  clinical  features  of  myxedema  ? 

2Iyxed€ma  is  a  peculiar  condition,  apparently  more  common 
in  women  than  in  men,  in  which  a  mucoid  substance  is  found 
in  the  subcutaneous  tissue  in  various  parts  of  the  body,  in  asso- 
ciation with  anemia,  atrophy  of  the  thyroid  gland  and  mental 
impairment.  The  condition  has  been  termed  sjjoro.dAc  cretinoid- 
ism  in  distinction  from  sporadic  cretinism. 

The  patient  becomes  dull,  stupid  and  irritable  ;  speech  thick 
and  hesitant ;  the  meiuory  enfeebled.  Movement  is  awkward  and 
clumsy,  and  there  is  undue  readiness  of  fatigue.  SensiMliiy  is 
impaired,  while  abnormal  sensations  of  heat  and  of  chilliness 
are  perceived.     There  may  be  visible  flushing. 

The  heart  is  slow  and  feeble,  the  respiration  sluggish,  with 
breathlessness  on  exertion ;  the  temperature  is,  as  a  rule,  sub- 
normal ;  the  appetite  is  impaired,  and  taste  is  deranged ;  the 
digestion  is  enfeebled ;  the  nutrition  is  poor,  the  urine  is  reduced 
in  quantity,  and  late  in  the  disease  may  be  albuminous.  In 
women  menorrhagia  is  common. 

The  face  is  pallid  and  puffy,  and  of  roundish  ("'full-moon") 
outline ;  the  expression  is  dull  and  stupid ;  the  ttiyroid  gland  is 
diminutive  or  absent.  The  tongue  is  enlarged,  and  swellings 
form  above  the  clavicles.  The  teeth  may  become  carious  and 
fall  out.  Speech  is  slow,  thick,  monotonous,  measured.  There 
may  be  choking  sensations  and  difficulty  in  swallowing.  The 
skin  is  thickened,  dry,  rough,  sometimes  scaly,  somewhat  trans- 
lucent in  appearance,  of  a  doughy  consistence,  but  with  a 
25 


386 


ESSENTIALS   OF   DIAGNOSIS. 


Fig.  55. 


certain  degree  of  elasticity ;  there  is  no  edema  and  no  pitting 
on  pressure  ;  perspiration  is  diminished.  Tlie  hands,  if  affected, 
become  square  or  "  spade-shaped";  the  fingers  ckibbed;  and  the 

nails  brittle  and  distorted.  The 
hair  is  dry  and  harsh  and  brit- 
tle, and  may  fall  out. 

In  the  progress  of  the  case 
mental  and  physical  failure 
increases,  irritability  becomes 
marked,  hallucinations  develop, 
stupor  sets  in,  and  death  may 
take  place  in  coma,  from  ex- 
haustion or  from  uremia. 

A  condition  resembling  myx- 
edema, occurring  in  circum- 
scribed areas  in  various  situa- 
tions— cachexia  strumipriva — has 
been  induced  in  man  and  in 
animals  by  removal  of  the  thy- 
roid gland.  Myxedema  has  fol- 
lowed exophthalmic  goiter. 

How  are  myxedema  and  sclero- 
derma to  be  differentiated? 

In  a  given  case  the  diagnosis 
between  myxedema  and  sclero- 
derma may  be  exceedingly  dif- 
ficult. In  scleroderma,  however, 
the  skin  is  brawny  and  indu- 
rated ;  not  elastic  and  doughy, 
as  in  myxedema.  In  sclero- 
derma, too,  the  thyroid  gland 
remains  unaffected,  while  the 
mental  phenomena  of  myxe- 
dema are  wanting.  The  histo- 
logic changes  in  the  two  condi- 
tions differ :  in  scleroderma 
there  is  hyperplasia  of  the  subcutaneous  connective  tissue ;  in 
myxedema  there  is  a  mucoid  deposit  or  degeneration. 


Myxedema.    (Personal  observation 


AKROMEGALY. 


387 


How  are  myxedema  and  obesity  or  adiposis  to  be  differen- 
tiated? 

The  various  forms  of  fat-deposition  and  fat-accumulation  bear 
only  a  remote  resemblance  to  myxedema.  They  may  be  diffuse 
or  circumscribed  in  various  situations.  The  nature  of  the 
tissues  is,  however,  different,  and,  accordingly,  while  myx- 
edema yields  a  somewhat  brawny  feeling,  adiposis  yields  a 
lobulated  or  worm-like  feeling.  Mental  and  trophic  alterations 
are  more  pronounced  in  myxedema  than  in  adiposis.     Thyroid 

Fig.  55. 


Dolorose  adiposis.     (Personal  observation.) 

atrophy  is  distinctive  of  myxedema;  the  thyroid  gland  may 
apparently  be  unchanged  in  adiposis.  A  dolorose  form  of 
adiposis  has  been  described. 


Akromegaly. 

What  is  akromegaly  ? 

Akromegaly  is  a  morbid  condition  characterized  by  increase  of 
the  distal  parts  of  the  extremities  in  thickness,  but  not  corre- 


388 


ESSENTIALS   OF   DIAGNOSIS. 


Fig.  57. 


spondingly  in  length,  the  bones  of  the  hands  and  feet  and  face 

being  especially  affected.     Some  of  the  fibro-cartilages,  as  those 
of  the  ear  and  larynx,  also  become  enlarged.     The  related  soft 

parts  undergo  corresponding  en- 
largement. There  develop  de- 
cided weakness  and  slight  mus- 
cular atrophy.  The  interosseous 
spaces  become  exaggerated. 
Owing  to  the  enlargement  of 
the  inferior  maxillary  and  the 
frontal  bones  the  face  assumes 
a  peculiarly  elongated,  elliptical 
outline.  The  hypertrophy  of  the 
nasal  bones  gives  the  nose  a 
thickened  appearance.  The  en- 
largement of  the  malar  bones 
increases  the  normal  temporal 
fossse.  The  enlargement  of  the 
frontal  sinuses  and  the  projec- 
tion of  the  superciliary  ridges 
give  the  forehead  a  retreating 
appearance.  The  chin  is  prom- 
inent, and  the  lower  teeth  proj  ect 
beyond  the  plane  of  the  upper 
teeth.  The  tongue  is  enlarged 
and  thickened.  The  lips  and 
eyelids  may  also  be  thickened. 
There  are  increased  thirst,  usu- 
ally jDolyuria,  and  sometimes 
glycosuria.  The  appearance  may 
be  cachectic,  the  conjunctivse 
icteric.  There  is  commonly 
spinal  curvature,  usually  a  cer- 
vico-dorsal  kyphosis,  with  a  com- 
pensatory lumbar  lordosis.  The 
The  stature  is  at  first  increased, 


Akromegaly.    (Personal  observation.) 


abdomen  may  be  protuberant, 

but  later  it  may  be  diminished.   The  skin  is  thickened  and  may 

be  pigmented.  The  nails  are  excessively  developed  and  may  pre- 


AKROMEGALY.  389 

sent  longitudinal  striation.  There  may  be  severe  spontaneous 
pain;  headache  is  common.  There  may  be  somnolence.  In 
many  cases  varicose  veins  and  hemorrhoids  have  been  observed. 
In  individual  cases  there  has  been  hemianopsia,  limitation  of 
the  visual  fields,  blindness,  or  deafness.  In  women  menstrua- 
tion is  usually  deranged.  The  thyroid  gland  may  be  atrophied 
or  hypertrophied.  The  thymus  is  often  present,  sometimes  en- 
larged. The  disease  appears  most  commonly  in  young  adults, 
and  is  chronic  in  course. 

How  does  akromeg-aly  differ  from  osteitis  deformans,  Pag-et's 
disease  ? 
Tbe  disease  called  by  Sir  James  Paget  osteitis  deformans  more 
especially  involves  the  long  bones,  which,  while  they  become 

Fig.  58. 


Outline  of  the  face,  1,  in  myxedema;  2,  in  akromegaly ;  3,  in  osteitis  deformans. 

(Marie.) 

enlarged,  also  become  distorted,  with  resulting  deformities; 
akromegaly  displays  a  predilection  for  the  small  bones  of  the 
hands  and  feet  and  face,  and  is  miattended  with  distortion  and 
deformity.  In  osteitis  deformans,  as  a  result  of  the  enlargement 
of  the  cranial  bones,  the  face  presents  a  triangular  outline,  with 
the  base  above  and  the  apex  below ;  in  akromegaly  the  enlarge- 
ment of  the  bones  of  the  face  occasions  a  characteristic  elongated, 
elliptical  outline.  In  akromegaly  there  may  be  an  increase  in 
stature;  in  osteitis  deformans  there  is  more  likely  to  be  a  dim- 
inution. The  former  appears  earl}-,  between  fifteen  and  thirty- 
five  ;  the  latter,  later,  after  forty.     Akromegaly  may  appear  in 


390 


ESSENTIALS   OF   DIAGNOSIS. 


several  members  of  one  family ;  osteitis  deformans  does  not. 
The  invasion  of  akromegaly  is  symmetrical;  that  of  osteitis 
deformans  is  indiscriminate. 

How  may  the  differential  diagnosis  between  akromegaly  and 
myxedema  be  made  ? 

The  enlargement  that  appears  in  myxedema  is  dependent 
upon  changes  in  the  skin  and  subcutaneous   soft  structures ; 


Fig.  59. 


Hand  from  a  case  of  empyema  with  pulmonary  hypertrophic  osteo-artbropathy. 

(Personal  observation.) 

while  the  enlargement  of  akromegaly  is  due  to  a  hyperplasia 
of  bone.  In  the  latter  the  skin  is  healthy  and  mobile;  in  the 
former  it  is  thickened  and  adherent.  In  myxedema,  in  con- 
trast to  akromegaly,  the  hands  and  feet  may  be  entirely  unin- 
volved.  In  myxedema  the  face  is  almost  round,  "  moon- 
shaped;"  in  akromegaly  it  is  elliptical  and  elongated,  with  a 
prominent  lower  jaw,  prominent  malar  processes  and  promi- 
nent nasal  bones. 


AKROMEGALY. 


391 


How  is  akromegcaly  to  be  discriminated  from  pulmonary 
hypertrophic  osteo-arthropathy  ? 

Under  a  name  signifying  ''hypertrophic  disease  of  hones  and 
joints  in  association  ivith  pulmonary  lesion,^'  Marie  has  described 
a  group  of  cases  presenting,  in  connection  with  empyema, 
pleurisy,  chronic  bronchitis,  tuberculous  disease  of  the  lungs, 
and  possibly  other  disease  of  the  lungs  and  their  appendages, 
skeletal  changes  somewhat  resembling  those  of  akromegaly. 

There  are  kyphosis,  enlargement  of  the  distal  epiphyses  of 
the  bones  of  the  forearm  and  of  the  leg,  and,  most  characteristic, 
an  enlargement  in  all  directions  of  the  distal  phalanges  of  both 
fingers  and  toes,  with  the  peculiar  curvation  of  the  nails  that 
gives  rise  to  the  so-called  Hippocratic  finger.  The  lower  jaw 
projects,  but  not  so  markedly  as  in  akromegaly,  and  the  other 
facial  bones  are  not  enlarged  ;  on  the  contrary,  the  features  are 
usually  sharpened. 

There  is  commonly  dulness  on  percussion  over  the  manubrium 
sterni,  supposably  dependent  upon  the  persistence  of  the  thymus 
gland.     The  thyroid  gland  may  be  wanting. 


Akromegaly. 

Stature  heiglitened. 
Cervico-dorsal  kyphosis. 
Projection  of  abdomen. 
Enlargement  of  face. 
Macroglossia. 

Hands  broadened — spade-like. 
Digits  uniformly  enlarged. 
Nail  short,  broad,  flat,  not  reach- 
ing end  of  finger. 

Epiphyseal  enlargements  uncom- 
mon. 

Polyuria  and  disturbance  of  special 
senses. 


PULMOXART  OSTEO-  ARTHROPATHY. 

Stature  not  heightened. 

Dorso-lumbar  kyphosis. 

No  projection  of  abdomen. 

No  enlargement  of  face. 

Tongue  not  enlarged. 

Hands  lengthened — not  spade-like. 

Terminal  phalanges  enlarged. 

Hippocratic  nail — curved,  longi- 
tudinally striated,  overlapping 
finger,  "parrot-beak-like." 

Epiphyseal  enlargements  the  rule. 

Intra-thoracic  disease. 


392 


ESSENTIALS   OF    DIAGNOSIS, 

Vu:.  (ill. 


Rhizomelic  spondylosis.    (Personal  observation.) 


Rhizomelic  Spondylosis. 

What  is  rhizomelic  spondylosis  ? 

This  is  a  disorder  characterized  by  hyperplastic  alterations  in 
the  joints  of  the  spinal  column  and  of  those  between  the  trunk 
and  the  extremities,  leading  to  deformity  and  impaired  mo- 
bility. Sometimes  spinal-nerve  roots  become  included  in  the 
morbid  process,  with  the  development  of  corresponding  sensory 
or  motor  symptoms. 


INDEX. 


Abortive  typhoid  fever,  39 
Abscess,  cerebral,  349 
Abscess,     cerebral,      diflferentiated 
from — 
cerebral  meningitis,  350 
cerebritis,  350 
tumor  of  the  brain,  350 
Abscess,  gen i to-urinary,  274 
Abscess,  lumbar,  differentiated 
from — 
perityphlitis,  230 
typhlitis,  230 
Abscess  of  the  kidney,  295 
Abscess  of  the  kidney  differentiated 

from  perinephric  abscess,  296 
Abscess  of  the  liver,  250 
Abscess  of  the  liver  differentiated 
from — 
actinomycosis  of  the  liver,  251 
carcinoma  of  the  liver,  251 
hydatid  cyst  of  the  liver,  257 
occlusion    of  the    biliary   pas- 
sages, 251 
pleuritic  effusion,  168 
Abscess  of  the  mediastinum  differ- 
entiated  from  aneurism   of   the 
aorta,  142 
Abscess  of  the  right  ovary  differen- 
tiated from — 
peritvphlitis,  230 
typhlitis,  230 
Abscess  of  the  spleen  differentiated 

from  pleuritic  effusion,  168 
Abscess,  perinephric,  296 
Abscess,  perinephric,  differentiated 

from  abscess  of  the  kidney,  296 
Abscess,  pulmonary,  differentiated 
from — 
bronchiectasis,  173 
pulmonary  gangrene,  182 
pulmonary  infarction,  181 
pulmonary  tuberculosis,  190 
Abscess,  retro-pharyngeal,  210 


Abscess,  retro-pharyngeal,  differen- 
tiated from  membranous  croup, 
156 

Abscess,  subphrenic,  differentiated 
from  pneumothorax,  197 

Absorptive  activity  of  gastric  mu- 
cous membrane,  214 

Acetone  in  the  urine,  tests  for  the 
presence  of,  286 

Achylia  gastrica,  215 

Aciditj^  of  gastric  contents,  212 

Aciditv,  total,  of  the  gastric  con- 
tents, 212 

Acids,  biliary,  in  the  urine,  271 

Actinomycosis,  90 

Actinomycosis  of  the  liver  differen- 
tiated from  abscess  of  the  liver, 
251 

Action  of  the  heart,  120 

Acute  alcoholism,  362 

Acute  anterior  poliomyelitis,  318 

Acute  ascending  paralysis,  319 

Acute  bronchitis,  170 

Acute  bulbar  palsy,  323 

Acute  catarrhal  pharyngitis,  204 

Acute  croupous  pneumonia,  176 

Acute  dysentery,  226 

Acute  edema  of  the  larynx,  151 

Acute  endocarditis,  139 

Acute  enteritis,  223 

Acute  gastric  catarrh,  215 

Acute  gastritis,  215 

Acute  general  disease  differentiated 
from  cerebral  meningitis,  343 

Acute  gout,  99 

Acute  hepatitis,  247 

Acute  indigestion,  215 

Acute  infective  jaundice,  67 

Acute  intestinal  catarrh,  223 

Acute  laryngitis.  150 

Acute  mania.  344,  363 

Acute  miliary  tuberculosis,  191 

Acute  myelitis,  315 

393 


394 


INDEX. 


Acute  nasal  catarrh,  148 

Acute  nephritis,  292 

Acute  pancreatitis,  265 

Acute  pericarditis,  235 

Acute  peritonitis,  241 

Acute  ijhlegmonous  pharyngitis, 
204 

Acute  pleurisy,  165 

Acute  rheumatism,  95 

Acute  synovitis,  97 

Acute  tuberculous  laryngitis,  152 

Acute  tuberculous  pharyngitis,  205 

Acute  yellow  atrophy  of  the  liver, 
248 

Addison's  disease,  116 

Adiposis,  387 

Ague,  dumb,  58 

Ague-cake,  59 

Air-passages,  obstruction  of,  differ- 
entiated from  croup,  155 

Air-passages,  upper,  diseases  of,  146 

Akoria,  214 

Akromegaly,  387 

Akromegaly  differentiated  from — 
myxedema,  390 
osteitis  deformans,  or  Paget's 

disease,  389 
pulmonary  hypertrophic  osteo- 
arthropathy, 391 

Akromikria,  340 

Albumin  in  urine,  tests  for,  275 

Albuminuria,  275 

Alcoholic  intoxication  differen- 
tiated from  cerebral  hemorrhage, 
353 

Alcoholism,  acute,  differentiated 
from  sunstroke,  362 

Ambulatory  typhoid  fever,  39 

Amyloid  disease  of  the  liver,  254 

Amyloid  disease  of  the  liver  differ- 
entiated from — 
cai-cinoma  of  the  liver,  255 
cirrhosis  of  the  liver,  254 

Amyloid  kidney,  293 

Amvotrophic  lateral  sclerosis,  320, 
321 

Anacidity,  215 

Analgesic  panaris,  340 

Anamnesis,  19 

Anemia,  106 

Anemia,  cerebral,  347 

Anemia,  diagnosis  of,  108 

Anemia  differentiated  from  cere- 
bral tumor,  358 

Anemia,  idiopathic,  107 


Anemia,  infantile  pseudo-leukemic, 
112 

Anemia,  lymjjhatic.  111 

Anemia  of  the  spinal  cord,  314 

Anemia,  pernicious,  107 

Anemia,  simple,  106 

Anemia,  splenic,  106 

Anesthesia,  300 

Anesthetic  leprosy,  340 

Aneurism,  intracranial,  358 

Aneurism  of  the  aorta  differentiated 
from — 
abscess    of    the    mediastinum, 

142 
aortic  incompetency,  142 
dilatation  of  the  auricle,  143 
intra-thoracic  tumor,  142 
pulsating  pleurisy,  143 

Aneurism,  thoracic,  141 

Angina,  204 

Angina  pectoris,  128 

Angina      pectoris      differentiated 
from — 
intercostal  neuralgia,  128 
tachycardia,  126 

Angina,  ulcero-membranous,  208 

Angioneurotic  edema,  146 

Ankylostomiasis,  239 

Anorexia,  nervous,  214 

Anthrax,  89 

Aorta,  aneurism  of,  141,  142 

Aortic  incompetency  or  regurgita- 
tion, 133 

Aortic  incompetency  or  regurgita- 
tion differentiated  from  aneurism 
of  the  aorta,  142 

Aortic  obstruction,  133 

Apex-beat  of  the  heart,  118 

Aphonia,  hysterical,  151 

Aphthous  stomatitis,  200 

Appendicitis,  228 

Appendicitis,  differential  diagnosis 
of,  230 

Arachnitis,  342 

Ardent  fever,  31 

Arsenical  poisoning  differentiated 
from  Asiatic  cholera,  52 

Arterial  hypermyotrophy,  144 

Arterio-capillary  fibrosis,  143 

Arthritic  muscular  atrophy,  326 

Arthritis  deformans,  102 

Arthritis,  rheumatoid,  102 

Arthritis,  syphilitic,  97 

Ascaris  lumbricoides,  237 

Asiatic  cholera,  50 


INDEX 


395 


Asphyxia  dififerentiated  from  cere- 
bral hemorrhage,  354 
Asphyxia,  local,  144 
Astasia-abasia,  373 
Asthenic  bulbar  paralysis,  324 
Asthma,  199 
Asthma  differentiated  from — 

an  asthmatoid  condition,  198 
chronic  edema  of  the  larynx, 

152 
laryngismus  stridulus,  153 
paralysis    of     the    diaphragm, 

198 
whooping-cough,  198 
Ataxia,  299,  300 
Ataxia,  Friedreich's,  331 
Ataxia,  locomotor,  327 
Ataxia,  vasomotor,  384 
Ataxic  paraplegia,  330 
Ataxic  paraplegia,  hereditary,  331 
Atelectasis  differentiated  from  ca- 
tarrhal pneumonia,  176 
Atrophy,  muscular,  arthritic,  326 
Atrophy,  muscular,  progressive,  320, 

321 
Atrophy,  muscular,  progressive,  dif- 
ferentiated from — 
acute     anterior    poliomyelitis, 

323 
cervical  pachymeningitis,  313 
chronic  myelitis,  317 
progressive     neural    muscular 

atrophy,  323 
syringomyelia,  339 
Atrophy,  progressive   neural  mus- 
cular, 323 
Atrophy,  yellow,  acute,  of  the  liver, 

248 
Atrophy,  yellow,  acute,  of  the  liver 
differentiated  from— 
catarrhal  jaundice,  260 
phosphorus-poisoning,  249 
typhoid  fever,  249 
yellow  fever,  66 
Aural  vertigo,  381 
Auricle,  dilatation  of,  143 
Auscultation,  162 
Auscultation  of  the  heart-sounds, 

122 
Auscultatory  percussion,  162 
Autumnal  catarrh,  149 

Banti's  disease,  265 
Basedow's  disease,  381 
Beriberi,  63,  303 


Bile-duct,  common,  compression  of, 

2(J0 
Biliary  acids  in  the  urine,  271 
Biliary  calculi,  261 
Biliary  coloring-matter  in  urine,  271 
Biliary  passages,  carcinoma  of,  262 
Biliary  passages,  occlusion  of,  251 
Black  tongue,  203 
Bladder,  neoplasms  of,  289 
Blood,  104 

Blood,  constitution  of,  104 
Blood  in  disease,  113 
Blood-casts     of     the      uriniferous 

tubules,  278 
Boas's  test  for  hydrochloric  acid,  212 
Boettger's  test  for  the  presence  of 

sugar  in  the  urine,  285 
Bone,  disease  of,  differentiated  from 

neuritis,  303 
Bothriocephalus  latus,  236 
Bowel,  invagination  or  intussuscep- 
tion of,  232 
Bowel,  perforation   of,  in   typhoid 

fever,  40 
Brachycardia,  127 
Break -bone  fever,  83 
Breathing,  superior  intercostal,  dif- 
ferentiated from  paralysis  of  the 
phrenic  nerve,  308 
Bronchial  glands,   tuberculosis   of, 

158 
Bronchiectasis,  173 
Bronchiectasis  differentiated  from — 
catarrhal  pneumonia,  173 
pulmonary  abscess,  173 
pulmonary  gangrene,  173 
pulmonary  tuberculosis,  190 
Bronchitis,  acute,  170 
Bronchitis,     acute,     differentiated 
from  acute  miliary  tuberculosis, 
171 
Bronchitis,  capillary,  174 
Bronchitis,  capillary,  differentiated 
from — 
acute  miliary  tuberculosis,  174 
catarrhal  pneumonia,  175 
Bronchitis,    chronic,   differentiated 
from — 
interstitial  pneumonitis,  172 
pulmonary  tuberculosis,  172 
Bronchitis,  plastic  or  fibrinous,  172 
Bronchitis,  putrid,  172 
Bronchophony,  164 
Broncho-pneumonia,  175 
Brow-ague,  59 


396 


INDEX. 


Bruslimakers'  disease,  89 
Bubonic  plague,  62 
Bulbar  palsy,  acute,  323 
Bulbar  paralysis,  asthenic,  324 
Bulbar  paralysis,  progressive,  321 
Bulimia,  214 

Cachexia,  malarial,  58 
Cachexia  strumipriva,  386 
Calculi,  biliary,  261 
Calculi,biliary, differentiated  from — 
carcinoma  of  the  biliary  pass- 
ages, 262 
catarrhal  jaundice,  259 
Calculus,  renal,  291 
Calculus,  vesical,  289 
Cancrum  oris,  201 
Capillary  bronchitis,  174 
Caput  Medusae,  252 
Carcinoma  of  the  biliary  passages 
differentiated  from  biliary  calculi, 
262 
Carcinoma  of  the  cecum  dilierentl- 
ated  from — 
perityphlitis,  231 
typhlitis,  231 
Carcinoma  of  the  intestine,  233 
Carcinoma  of  the  liver,  254 
Carcinoma  of  the  liver  differentiated 
from — 
abscess  of  the  liver,  251 
amyloid  disease  of  the  liver,  255 
carcinoma  of  the  omentum,  255 
carcinoma  of  the  stomach,  256 
Carcinoma  of  the  omentum  differen- 
tiated from — 
carcinoma  of  the  liver,  255 
carcinoma  of  the  stomach,  222 
Carcinoma  of  the  pancreas,  265 
Carcinoma  of  the  pancreas  differen- 
tiated   from    carcinoma    of    the 
stomach,  222 
Carcinoma  of  the  stomach,  220 
Carcinoma  of  the  stomach  differen- 
tiated from — 
carcinoma  of  the  liver,  256 
carcinoma  of  the  omentum,  222 
carcinoma  of  the  pancreas,  222 
chronic  gastritis,  222 
sarcoma  of  the  omentum,  222 
ulceration  of  the  stoma(;]i.  221 
Carcinoma,    pulmonai'y,    differenti- 
ated   from    pulmonary   tubercu- 
losis, 180 
Cardia,  insufficiency  of,  214 


Cardia,  spasm  of,  214 
Cardiac  impulse,  118 
Caries  of  the  vertebriE  differentiated 
from  tumor  of  the  spinal  cord,  338 
Casts   of  the   uriuiferous    tubules, 

278 
Catarrh,  acute  nasal,  148 
Catarrh,  autumnal,  149 
Catarrh,  epidemic,  32 
Catarrh,  gastric,  acute,  215 
Catarrh,  gastric,  chronic,  217 
Catarrh,  gastro-intestiual,  differen- 
tiated  from  pernicious  malarial 
fever,  60 
Catarrh,  intestinal,  acute,  223 
Catarrh,  intestinal,  chronic,  225 
Catarrhal  croup,  154 
Catarrhal  fever,  32 
Catarrhal  jaundice,  259 
Catarrhal  pharyngitis,  acute,  204 
Catarrhal  pneumonia,  175 
Catarrhal  stomatitis,  199 
Cavity,    pulmonary,    differentiated 

from  pneumothorax,  196 
Cecum,  carcinoma  of,  231 
Cerebellar  tumor,  329,  331 
Cerebral  abscess,  349 
Cerebral  anemia,  347 
Cerebral  congestion,  352 
Cerebral  disease  differentiated  from 

epilepsy,  371 
Cerebral  disease,  paralysis  of,  differ- 
entiated  from    the    paralysis    of 
hysteria,  374 
Cerebral  embolism,  355 
Cerebral  functions,  alterations  in,  in 
disease  of  the  nervous  system,  302 
Cerebral  hemorrhage,  350 
Cerebral  hyperemia,  348 
Cerebral    membranes,   hemorrhage 

into,  345 
Cerebral  meningitis,  342 
Cerebral  softening,  354 
Cerebral  thrombosis,  356 
Cerebral  tumor,  357 
Cerebri tis,  349 

Cerebritis  differentiated  from — 
cerebral  abscess,  350 
cerebral  meningitis,  349 
Cerebro-spinal  fever,  46 
Cerebrospinal  fever  differentiated 
from — 
cerebral  meningitis,  344 
tetanus,  48 
torticollis,  49 


INDEX. 


397 


Cerebro-spinal   fever  differentiated 
froui — 
tyi)hoid  fever,  50 
typhus  fever,  48 
variola,  49 
yellow  fever,  49 
Cerebro-spinal  sclerosis,  332 
Cervical  pachymeningitis,  313 
Chalk-stones,  101 
Cimrbon,  89 
Chickcnpox,  79 

Chickenpox  differentiated  from — 
measles,  gO 
smallpox,  79 
varioloid,  79 
Chlorosis,  107 
Cholangitis,  258 
Cholecystitis,  258 
Cholera  Asiatica,  50 
Cholera      Asiatica      differentiated 
from — 
arsenical  poisoning,  52 
cholera  morbus,  52,  225 
Cholera  differentiated  from  perni- 
cious malarial  fever,  60 
Cholera  infantum,  225 
Cholera  infectiosa,  50 
Cholera  morbus,  225 
Cholera  morbus  differentiated  from 

cholera  Asiatica,  52,  225 
Cholera  nostras,  225 
Chorea,  367 

Chorea  differentiated  from— 
epilepsy,  371 
spasmodic  tic.  369 
Chorea,  hereditary,  369 
Chorea,  Huntingdon's.  369 
Chronic  bronchitis.  171 
Chronic  dysentery.  227 
Chronic  edema  of  the  larynx,  152 
Chronic  enteritis,  225 
Chronic  gastric  catarrh,  217 
Chronic  gastritis.  217 
Chronic  gout,  101 
Chronic  herpes  of  throat,  200 
Chronic  interstitial  nephritis._293 
Chronic  intestinal  catarrh,  225 
Chronic  laryngitis.  158 
Chronic  myelitis.  316 
Chronic  nephritis,  358 
Chronic  parenchvmatous  nephritis, 

292 
Chronic  peritonitis,  243 
Chronic  pharyngitis,  205 
Chronic  pleurisy,  169 


Chronic  rheumatism,  99 

Chronic  tonsillitis,  208 

Chronic  tuberculosis  of  the  larynx, 

159 
Chyluria,  278 
Cirrhosis  of  the  liver,  252 
Cirrho.sis  of  the  liver  differentiated 
from — 
amyloid  disease  of  the  liver,  254 
catarrhal  jaundice,  260 
chronic  perihepatitis,  258 
Clavus  hystericus,  373 
Colic,  hepatic,  intestinal  and  renal, 

differential  diagnosis  of,  262 
Colic,  intestinal,  differentiated  from 

acute  peritonitis,  242 
Colic,  mucous,  224 
Color  of  urine,  267 
Coloring-matter,  biliary,  in  urine, 

271 
Common   membranous  sore-throat, 

208 
Complications  in  disease,  22 
Compression  of  the  common  bile- 
duct  differentiated  from  catarrhal 
jaundice,  260 
Compression,  spinal,   336 
Compression,   spinal,  differentiated 

from  chronic  myelitis.  337 
Compression-myelitis  differentiated 
j      from  hemorrhage  into  the  spinal 
I      cord,  337 
!  Confluent  smallpox,  76 
'  Congenital  spastic  paraplegia.  346 
Congestion,  cerebral,  differentiated 

from  cerebral  hemorrhage,  352 
Congestion  of  the  liver,  246 
Congestion,  pulmonary,  differenti- 
ated  from  croupous  pneumonia, 
180 
Constitution  of  urine.  267 
Constitutional  symptoms.  19 
Consumption,  galloping.  183,  188 
Continued  fever,  30 
'  Convulsion,  300 
;  Cord,  spinal,  anemia  of.  314 
Cord,  spinal,  hyperemia  of,  315 
Coryza,  148 

Coryza  differentiated  from — 
hay-fever,  149 
influenza.  148 
Coryza,  idiosyncratic,  149 
Coryza,  periodic  vasomotor,  149 
Cramp,  writers',  367 
Cretinism,  384 


398 


INDEX. 


Cretinoidism,  sporadic,  385 

Croup,  catarrhul,  154 

Croup,  catarrhal,  differentiated  from 

laryn^ijismus  stridulus,  154 
Croup  ditlereiitiated  from — 

edema  of  the  larynx,  154 

obstruction  of  the  air-passages, 
155 
Croup,  membranous,  155 
Croup,  membranous,  differentiated 
from — 

catarrhal  croup,  156 

diphtheria,  87 

retro-pharyngeal  abscess,  156 

spasmodic  croup,  156 

whooping-cough,  157 
Croup,  spasmodic,  154 
Croup,      spasmodic,     differentiated 
from — 

edema  of  the  larynx,  154 

laryngismus  stridulus,  154 

membranous  croup,  156 
Croupous  pneumonia,  176 
Cystitis,  274,  288 
Cystitis  differentiated  from — 

nephritis,  288 

pyelitis,  290 
Cysts,  pancreatic,  266 


Data  for  diagnosis,  24 

Deep  reflexes,  301 

Degeneration,  fatty,  of  the  heart, 

130 
Degeneration    of    the    diaphragm, 

308 
Degeneration,  reaction  of,  301 
Delirium  tremens,  363 
Delirium     tremens     differentiated 
from — 

acute  mania,  363 

cerebral  meningitis,  363 
Dementia,  paretic,  359 
Dengue,  83 
Dengue  differentiated  from — 

influenza,  84 

scarlet  fever,  84 

yellow  fever,  66 
Dermatitis,  acute  exfoliative,  differ- 
entiated from  scarlet  fever,  73 
Dermatitis,     toxic,     differentiated 

from  scarlet  fever,  73 
Deuteropathic  fever,  30 
Dextrocardia,  125 
Diabetes  insipidus,  282 


Diabetes    insipidus    differentiated 
from — 
chronic    interstitial   nephritis, 

283 
diabetes  mellitus,  287 
hysterical  polyuria,  283 
Diabetes  mellitus,  283 
Diabetes     mellitus     differentiated 
from — 
diabetes  insipidus,  287 
Morvan's  disease,  342 
Diacetic  acid  in  the  urine,  tests  for 

the  presence  of,  287 
Diaceturia,  287 
Diagnosis,  17 

Diagnosis  by  exclusion,  21 
Diagnosis  by  the  historical  or  em- 
pirical method,  20 
Diagnosis  by  the  inductive  method, 

20 
Diagnosis  by  the  method  of  patho- 
logical association,  20 
Diagnosis,  data  for,  24 
Diagnosis,  direct,  20 
Diagnosis,  discriminative  or  differ- 
ential, 21 
Diagnosis,  physical,  159 
Diaphragm,  degeneration  of,  differ- 
entiated   from    paralysis   of   the 
phrenic  nerve,  308 
Diaphragm,    inflammation    of,  dif- 
ferentiated from  paralysis  of  the 
phrenic  nerve,  308 
Diajihragm,  paralysis  of,  198 
Diaphragmatic  hernia,  196 
Diarrhea,  tubular,  224 
Differential  diagnosis,  21 
Digestive  activity  of  the  stomach, 

213 
Digestive  system,  199 
Dilatation  of  the  auricle  differenti- 
ated from  aneurism  of  the  aorta, 
143 
Dilatation  of  the  heart,  129 
Dilatation   of  the  heart  differenti- 
ated from — 
fatty  degeneration  of  the  heart, 

130 
hypertrophy  of  the  heart,  130 
pericardial  effusion,  130 
Dilatation  of  the  stomach,  218 
Diphtheria,  84 

Diphtheria  differentiated  from  com- 
mon .  membranous  sore-throat, 
209 


INDEX 


399 


Diphtheria  differentiated  from — 

gangrenous  sore-throat,  209 

membranous  croup,  87 

scarlet  fever,  86 

stomatitis,  87 

tonsillitis,  86 
Diplitheroid  throat.  208 
Diplegia,  2i)9 
Direct  diagnosis,  20 
Discrete  smallpox,  76 
Discriminative  diagnosis,  21 
Displacements  of  the  kidney,  290 
Disseminated  neuritis,  303 
Disseminated  sclerosis,  332 
Distention  of  the  gall-bladder  dif- 
ferentiated from  hydatid  cyst  of 
the  liver,  258 
Distomiasis,  239 
Dracontiasis,  95 
Drug-effects,  23 
Dumb  ague.  58 

Duplication  of  the  heart-sounds,  120 
Dysentery,  acute,  226 
Dysentery,     acute,     differentiated 
from — 

acute  enteritis,  227 

intussusception  of   the  bowel, 
226 

typhoid  fever,  227 
Dysentery,  chronic,  227 
Dvstrophy,    progressive    muscular, 
324 

EcHiNococcus  disease,  92 
Eclampsia  differentiated  from  epi- 
lepsy, 372 
Edema,  angioneurotic,  146 
Edema  of  the  larynx,  acute,  151 
Edema  of  the  larynx,  chronic,  152 
Edema  of  the  larynx,  chronic,  dif- 
ferentiated from  asthma,  152 
Edema  of  the  larynx  differentiated 

from  spasmodic  croup,  154 
Edema,   pulmonary,    differentiated 

from  pneumonia,  179 
Efficiency  of  the  heart,  121 
Effusion,  pericardial,  differentiated 
from — 
dilatation  of  the  heart,  130 
pericarditic  effusion,  145 
pleuritic  effusion,  162 
Effusion,     pleural,      differentiated 
from — 
pericardial  effusion,  169 
pneumothorax,  197 


Effusion,      pleural,     differentiated 
from    pulmonary    emphysema, 
195 
Effusion,    pleuritic,    differentiated 
from — 
abscess  of  the  liver,  168 
abscess  of  the  spleen,  168 
hydatid  cyst  of  the  liver,  167 
hydrothorax,  169 
Egophony,  165 
Electric  reactions,  alterations  in,  in 

disease,  301 
Embolism,  cerebral,  355 
Embolism,   cerebral,  differentiated 

from  cerebral  hemorrhage,  355 
Emphysema,  pulmonary,  194 
Emphysema,  pulmonary,  differenti- 
ated from — 
pleural  effusion,  195 
pneumothorax,  194 
Empirical  method,  diagnosis  by,  20 
Emprosthotonos,  377 
Empyema,  165 
Empyema,  pulsatory,  166 
Endemic  hematuria,  282 
Endocardial  murmurs,  136 
Endocarditis,  139 

Endocarditis,  acute,   differentiated 
from — 
acute  pericarditis,  140 
valvular  disease  of  the  heart, 
139 
Endocarditis,  malignant  or  ulcera- 
tive, 139 
Endocarditis,  simple  or  vegetative, 

139 
Enlargement  of  the  spleen,  264 
Enteric  fever,  35 
Enteritis,  acute,  223 
Enteritis,  acute,  differentiated 
from — 
acute  dysentery,  227 
acute  peritonitis,  242 
Enteritis,  catarrhal,  acute,  differen- 
tiated from  typhoid  fever,  224 
Enteritis,  chronic,   225 
Enteritis,  membranous,  224 
Enteritis,  mucous,  acute,  223 
Ephemeral  fever,  31 
Epidemic  catarrh,  32 
Edidemic  cerebro-spinal  meningitis, 

46 
Epilepsy,  370 

Epilepsy  differentiated  from  aural 
vertigo,  381 


400 


INDEX. 


Epilepsy  differentiated  from — 

cerebral  disease,  371 

cerebral  tunior,  358 

chorea,  371 

eclampsia,  372 

hysteria,  374 

syncope,  371 

uremia,  294,  372 
Epilepsy,  essential,  370 
Epilepsy,  idiopathic,  370 
Epilepsy,  major,  370 
Epilepsy,  minor,  370 
Epistaxis,  148 
Epithelial  casts  of  the  uriniferous 

tubules,  278 
Equinia,  87 

Eructations,  nervous,  214 
Eruptive  fevers,  68 
Erysipelas,  80 
Erysipelas  differentiated  from — 

erythema,  81 

herpes  zoster,  81 

scarlet  fever,  81 

smallpox,  82 
Erythema  differentiated  from  ery- 
sipelas, 81 
Erythromelalgia,  145 
Erythromelalgia    differentiated 

from  Raynaud's  disease,  145 
Esophagismus,  212 
Esophagitis,  211 
Esophagus,  211 

Esophagus,  inflammation  of,  211 
Esophagus,  stricture  of,  211 
Essential  epilepsy,  370 
Essential  fever,  30 
Examination  of  urine,  267 
Exanthemata,  68 
Exclusion,  diagnosis  by,  21 
Exophthalmic  goiter,  381 
Exophthalmic  goiter  differentiated 
from — 

simple  goiter,  384 

tachycardia,  126 


Facial  hemiatrophy,  306 
Facial  nerve,  paralysis  of,  306 
Family  history,  19 
Family  periodic  paralysis,  377 
Famine-fever,  44 
Farcy,  87 

Fatty  casts  of  the  uriniferous  tub- 
ules, 278 


Fatty  degeneration  of  the  heart  dif- 
ferentiated from  dilatation  of  the 
heart,  130 

Fatty  infiltration  of  the  liver,  253 

Fatty  liver,  253 

Fatty  metamorphosis  of  the  liver, 
253 

Febricula,  31 

Febrile  temperature,  28 

Fehling's  test  for  the  presence  of 
sugar  in  the  urine,  286 

Fermentation-test  far  the  presence 
of  sugar  in  the  urine,  286 

Fever,  27 

Fever,  ardent,  31 

Fever,  break-bone,  83 

Fever,  catarrhal,  32 

Fever,  cerebro-spinal,  46 

Fever,  continued,  30 

Fever,  deuteropathic,  30 

Fever,  enteric,  35 

Fever,  ephemeral,  31 

Fever,  essential,  30 

Fever,  glandular,  82 

Fever,  hemorrhagic  malarial,  58 

Fever,  hepatic  intermittent,  262 

Fever,  idiopathic,  30 

Fever,  intermittent,  30 

Fever,  malarial  intermittent,  56 

Fever,  malarial  remittent,  57 

Fever,  Malta,  61 

Fever,  Mediteri-anean,  61 

Fever,  miliary,  82 

Fever,  Neapolitan,  61 

Fever  of  suppuration,  59 

Fever,  pernicious  malarial,  58 

Fever,  rag-weed,  149 

Fever,  relapsing,  52 

Fever,  remittent,  30 

Fever,  rheumatic,  95 

Fever,  scarlet,  70 

Fever,  simple  continued,  31 

Fever,  specific,  30 

Fever,  splenic,  89 

Fever,  spotted,  47 

Fever,  symptomatic,  30 

Fever,  syphilitic.  61 

Fever,  thermic,  361 

Fever,  typhoid,  35 

Fever,  typhus,  44 

Fever,  undulant,  61 

Fever,  yellow,  64 

Fevers,  eruptive,  68 

Fibrinous  bronchitis,  17^ 


INDEX 


401 


Fibroid  phthisis,  183 

Fibrosis,  ;irtt.'rio-capillary,  143 

Fihiriasis,  9,"),  '279 

Floating  kidney,  291 

Floating  liver,  245 

Floating  spleen,  264 

Florid  phthisis,  183,  188 

Follicular  tonsillitis,  207 

Foot-aud-mouth  disease,  91 

Fremitus,  vocal  or  tactile,  160 

French  measles,  74 

Frequency  of  action  of  the  heart, 
120 

Friedreich's  ataxia,  331 

Frost-bite  ditierentiated  from  Eay- 
naud's  disease,  145 

Functional  heart-murmurs,  124 

Functional  stricture  of  the  esopha- 
gus, 212 

Gall-bladdek,  distention  of,  258 
Galloping  consumption,  183,  188 
Gangrene,  local  or  symmetrical,  144 
Gangrene,  pulmonary,  182 
Gangrene,  pulmonary,  differen- 
tiated from — 
bronchiectasis,  173 
pulmonary  abscess,  182 
pulmonary  tuberculosis,  182 
Gangrene,  symmetrical,  144 
Gangrenous  pharyngitis,  209 
Gangrenous  stomatitis,  201 
Gastralgia.  215 

Gastralgia  differentiated  from  gas- 
tric ulceration,  220 
Gastrectasis.  218 
Gastric  catarrh,  acute,  215 
Gastric  catarrh,  chronic,  217 
Gastric  contents,  acidity  of,  212 
Gastric  contents,  hvdrochloric  acid 

in,  212 
Gastric    contents,    lab-ferment    in, 

213 
Gastric  contents,  lactic  acid  in,  213 
Gastric  contents,  pepsin  in,  213 
Gastric  contents,  rennet-ferment'in, 

213 
Gastric  contents,  total  acidity  of, 

212 
Gastric  hemorrhage.  189 
Gastric  mucous  membrane,  absorp- 
tive activity  of,  214 
Gastric  ulcer,  218 
Gastric   ulceration   differentiated 
from  gastralgia,  220 

26 


Gastritis,  acute,  215 
Gastritis,   acute,   differentiated 
from — 
acute  peritonitis,  241 
intestinal  obstruction,  216 
the  gastric  symptoms  of  acute 
febrile  disease  or  of  cerebral 
disease,  216 
Grastritis,  chronic,  217 
Gastritis,     chronic,     differentiated 
from — 
carcinoma  of  the  stomach,  222 
gastric  ulcer,  219 
Gastrodynia,  214 
Gastro-enteritis,  223 
Gastro-intestinal  catarrh,  60 
Gastroptosis,  218 

General  paralysis  of  the  insane,  359 
General  symptoms,  19 
Genito-urinary  apparatus,  267 
Geographical  tongue,  203 
German  measles,  74 
Glanders,  87 

Glanders  differentiated  from — 
smallpox,  88 
syphilis,  88 
Glandular  fever,  82 
Globus  hystericus,  373 
Glossanthrax,  203 
Glossitis,  202 
Glosso-labio-laryngeal   paralysis, 

320,  321 
Glycosuria,  283 
Goiter,  exophthalmic,  381 
Goiter,  simple,  differentiated  from 

exophthalmic  goiter,  334 
Gonorrheal  synovitis,  97 
Gout,  acute,  99 
Gout,    acute,    differentiated     from 

acute  rheumatism,  100 
Gout,  chronic,  102 
Gout  differentiated  from    rheuma- 
toid arthritis,  104 
Grand  mal,  370 
Granular  casts   of  the   uriniferous 

tubules,  278 
Graves's  disease,  381 
Green-sickness,  107 
Grip]ie,  la,  32 

Giinzburg's    test    for   hydrochloric 
acid,  212 

Habit  CHOEEA,  369 
Habit-spasm,  369 
Hairy  tongue,  203 


402 


IND  EX 


Hay-asthma,  149 

Hay-fever,  149 

Hay-fever  differentiated  from  co- 
ryza,  149 

Headache  differentiated  from  mi- 
graine, 312 

Headache,  sick,  311 

Heart,  118 

Heart,  action  of,  120 

Heart,  action  of,  intermission  of,  120 

Heart,  apex-beat  of,  1 18 

Heart,  dilatation  of,  129 

Heart,  efficiency  of,  121 

Heart,  fatty  degeneration  of,  130 

Heart,  functional  disturbance  of, 
125 

Heart,  hypertrophy  of,  128 

Heart,  irritable,  127 

Heart,  malformation  of,  124 

Heart,  valvular  disease  of,  131 

Heart-clot,  140 

Heart-murmurs,  121 

Heart-murmurs,  organic,  differenti- 
ated from  functional,  124 

Heart-sounds,  auscultation  of,  120 

Heat-exhaustion,  36 

Heat-exhaustion  differentiatedfrom 
heat-fever  or  sunstroke,  362 

Heat-fever,  361 

Heat-stroke,  361 

Hematokrit,  104 

Hematuria,  279 

Hematuria,  endemic,  282 

Hematuria,  malarial,  differentiated 
from  paroxysmal  hemoglobinuria, 
281 

Hemiatrophy,  facial,  306 

Hemicrania,  311 

Hemiplegia,  299 

Hemocytometry,  104 

Hemoglobinometry,  105 

Hemoglobinuria,  280 

Hemoglobinuria,  paroxysmal,  281 

Hemoglobinuria,  paroxysmal,  dif- 
ferentiated from  malarial  hema- 
turia, 281 

Hemophilia,  116 

Hemorrhage,  cerebral,  353 

Hemorrhage,    cerebral,    differenti- 
ated from — 
alcoholic  intoxication,  353 
asphyxia,  354 
cerebral  congestion,  352 
cerebral  embolism,  355 
cerebral  thrombosis,  356 


Hemorrhage,      cerebral,      differen- 
tiated from — 
opium-poisoning,  353 
primary  lateral  sclerosis,  330 
sunstroke,  362 
syncope,  353 
uremia  354 
Hemorrhage,  gastric,  differentiated 
from  pulmonary  hemorrhage,  189 
Hemorrhage  into  the  cerebral  mem- 
branes, 345 
Hemorrhage  into  the  spinal  mem- 
branes, 314 
Hemorrhage  into  the  spinal  mem- 
branes differentiated  from — 
spinal  hemorrhage,  335 
spinal  meningitis,  314 
tetanus,  378 
Hemorrhage,  pancreatic,  266 
Hemorrhage,  pulmonary,  differenti- 
ated from  gastric  hemorrhage,  189 
Hemorrhage,  spinal,  335 
Hemorrhage,  spinal,  differentiated 
from — 
acute  myelitis,  316 
compression-myelitis,  337 
meningeal  hemorrhage,  335 
spinal  meningitis,  335 
Hemorrhagic  malarial  fever,  58 
Hemorrhagic  pachymeningitis,  383 
Hemorrhagic  smallpox,  77 
Hepatic  colic,  262 

Hepatic  intermittent  fever  differen- 
tiated from  malarial  intermittent 
fever,  262 
Hepatitis,  acute,  247 
Hepatitis,      acute,      differentiated 
from — 
malarial  cachexia,  247 
portal  phlebitis,  247 
Hepatitis,  interstitial,  252 
Hereditary  ataxic  paraplegia,  331 
Hereditary  chorea,  369 
Hernia,    diaphragmatic,  differenti- 
ated from  pneumothorax,  196 
Herpes,   chronic    or  recurrent,    of 

throat,  208 
Herpes  of  the  pharynx,  208 
Herpes   zoster   differentiated   from 

erysipelas,  81 
Herpetic  sore-throat,  208 
Herpetic  tonsillitis,  208 
Hip-joint,  disease  of,  differentiated 

from  sciatica,  305 
Hippuric  acid  in  urine,  269 


INDEX 


403 


Historical  method,  diagnosis  by,  20 
History,  family,  19 
History,  previous,  19 
Hodgkin's  disease.  111 
Humanized  virus,  77 
Huntingdon's  chorea,  369 
Hyaline   casts  of    the    uriniferous 

tubules,  278 
Hydatid  cyst,  93 
Hydatid  cyst  of  the  kidney,  298 
Hydatid  cyst  of  the  kidney  differ- 
entiated from  liydronephrosis,  298 
Hydatid  cyst  of  the  liver,  256 
Hydatid  cyst  of  the  liver  differenti- 
ated from — 

abscess  of  the  liver,  257 

distention  of  the  gall-bladder, 
258 

pleuritic  effusion,  167 
Hydatid  disease,  92 
Hydremia,  105 
Hydrocephalus,  345 
Hydrochloric   acid  in   the    gastric 

contents,  212 
Hydrochloric  acid,  tests  for,  212 

Boas's  test  for,  212 

Giinzburg's  test  for,  212 

Topfer's  test  for,  212 
HydroneiDhrosis,  297 
Hydronephrosis  differentiated  from 

cyst  of  the  kidney,  298 
Hydrophobia,  380 
Hydrophobia  differentiated  from — 

pseudo-hydrophobia,  380 

tetanus,  381 
Hydrothorax    differentiated    from 

pleuritic  effusion,  169 
Hyperacidity,  215 
Hyperchlorhydria,  215 
Hyperemia,  cerebral,  348 
Hyperemia  of  the  spinal  cord,  315 
Hyperesthesia,  300 
Hyperkinesis,  214 
Hyperleukocytosis,  108 
Hypermyotrophy,  arterial,  144 
Hyperpyrexia,  28 
Hypertrophic  pachymeningitis,  338, 

339 
Hypertrophy  of  the  heart,  128 
Hypertrophy  of  the  heart  differenti- 
ated from  dilatation  of  the  heart, 
130 
Hypesthesia,  300 
Hypoleukocytosis,  105 
Hysteria,  372 


Hysteria  differentiated  from — 
acute  meningitis,  375 
cerebral  tumor,  375 
epilepsy,  374 
neurasthenia,  376 
tetanus,  378 
Hysterical    aphonia    differentiated 

from  acute  laryngitis,  151 
Hysterical   paralysis  differentiated 
from  the  paralysis  of  cerebral  dis- 
ease, 374 
Hysterical  paraplegia  differentiated 
from — 
acute  myelitis,  375 
spastic  paraplegia,  375 
Hysterical  polyuria,  283 

Idiopathic  anemia,  107 
Idiopathic  epilepsy,  370 
Idiopathic  fever,  30 
Idiosyncratic  coryza,  149 
Immediate  percussion,  161 
Impulse,  cardiac,  118 
Inadequacy,  renal,  290 
Incompetency,  aortic,  133 
Incompetency,  aortic,  differentiated 

from  aneurism  of  the  aorta,  142 
Incompetency,  mitral,  132 
Incompetency,  pulmonary.  135 
Incompetency,  tricuspid,  134 
Indicanuria,  273 
Indigestion,  acute,  215 
Inductive  method,  diagnosis  by,  20 
Infantile  pseudo-leukemic  anemia, 

112 
Infantile  spastic  paraplegia,  346 
Infarction,    pulmonary,   differenti- 
ated from — 
catarrhal  pneumonia,  176 
croupous  pneumonia,  180 
pulmonary  abscess,  181 
Inflammation    of   the    diaphragm, 

306 
Inflammation    of    the     esophagus, 

211 
Influenza,  32 

Influenza,  abdominal  type  of.  34 
Influenza,  catarrhal  type  of,  33 
Influenza,  cerebral  type  of,  34 
Influenza,  diagnosis  of,  35 
Influenza  differentiated  from — 
coryza,  148 
dengue,  84 
Influenza,  gastrointestinal  type  of, 

34 


404 


INDEX 


Influenza,  nervous  type  of,  34 
Influenza,  thoracic  type  of,  33 
Influenza,  typhoid  type  of,  34 
Inquiry,  24 

Insane,  general  paralysis  of,  359 
Insolation,  361 
Inspection,  118,  146,  159 
Instrumental  signs,  18 
Insutflciency  of  the  cardia,  214 
Insufficiency  of  the  pylorus,  214 
Insular  sclerosis,  332 
Intercostal  neuralgia,  128,  167 
Intermission  of  the  heart's  action, 

120 
Intermittent  fever,  30 
Intermittent  fever,  hepatic,  262 
Intermittent  fever,  malarial,  56 
Interstitial  hepatitis,  252 
Interstitial  nephritis,  chronic,  293 
Interstitial  pneumonitis,  193 
Intestinal  catarrh,  acute,  223 
Intestinal  catarrh,  chronic,  225 
Intestinal  colic,  242,  262 
Intestinal  obstruction,  216,  231 
Intestinal  parasites,  234 
Intestines,  223 
Intestines,  carcinoma  of,  233 
Intoxication,  alcoholic,  353 
Intracranial  aneurism,  359 
Intra-thoracic  tumor,  142,  170 
Intussusception  of  the  bowel,  232 
Intussusception  of  the  bowel  differ- 
entiated from — 
acute  dysentery,  226 
obstruction  of  the  bowel,  233 
typhlitis,  233 
Invagination  of  the  bowel,  232 
Inverse  temperature,  28 
Irritable  heart,  127 
Irritable  heart  difl"erentiated  from 
tachycardia,  127 

Jail-fevee,  44 
Jaundice,  acute  infective,  67 
Jaundice,  catarrhal,  difl'erential  di- 
agnosis of,  259 

acute    yellow    atrophy   of   the 
liver,  260 
Jaundice,  catarrhal,  differentiated 
from — 
biliary  calculus,  259 
cirrhosis  of  the  liver,  260 
compression  of  the  common  bile- 
duct,  260 
malarial  fever,  260 


Jaundice,    catarrhal,  differentiated 
from — 

malignant  disease,  260 

pylephlebitis,  260 

Weil's  disease,  260 

yellow  fever,  260 
June-cold,  149 

Kak-ke,  63,  303 

Kidney,  abscess  of,  295 

Kidney,    amyloid,    lardaceous    or 

waxy,  293 
Kidney,  displacements  of,  290 
Kidney,  floating,  291 
Kidney,  hydatid  cyst  of,  298 
Kidney,  malignant  disease  of,  297 
Kidney,  movable,  291 
Kidney,  tuberculosis  of,  296 

Lab-ferment  in   gastric  contents, 

213 
Labyrinthine  vertigo,  381 
Lactic  acid,  test  for,  213 
Lacunal  tonsillitis,  207 
Landry's  paralysis,  319 
Lardaceous  kidney,  293 
Larval  paludism,  59 
Laryngeal  neoplasms  differentiated 

from  chronic  laryngitis,  158 
Laryngeal  vertigo,  153 
Laryngismus  stridulus,  153 
Laryngismus     stridulus      differen- 
ti^^ted  from — 
asthma,  153 
catarrhal  croup,  154 
whooping-cough,  157 
Laryngitis,  acute,  150 
Laryngitis,   acute,   differentiated 

from  hysterical  aphonia,  150 
Laryngitis,  acute  tuberculous,  152 
Laryngitis,  chronic,  158 
Laryngitis,    chronic,  differentiated 

from  laryngeal  neoplasms,  158 
Laryngitis  differentiated  from — 
parotiditis,  150 
pharyngitis,  150 
tonsillitis,  150 
Laryngitis,   pseudo-membranous, 

155  ^ 
Larvngitis,      tuberculous,       acute, 

152 
Laryngoscopy,  147 
Larynx,  edema  of,  151 
Larvnx,    tuberculosis    of,   chronic, 
159 


INDEX. 


405 


Lateral  sclerosis,  amyotrophic,  320, 
321 

Lateral  sclerosis,  primary,  329 

Load-poisoiiiug,  3(J4 

Lead-poisouing  ditferentiated  from 
cerebral  tumor,  365 

Lead-poisoning,  neuritis  of,  differ- 
entiated from  neuritis  of  the 
musculo-spiral  nerve,  309 

Leprosy,  63 

Leprosy,  anesthetic,  differentiated 
from  Morvan's  disease,  341 

Leprosy  differentiated  from  syringo- 
myelia, 339 

Leptomeningitis,  312,  342 

Leucin,  272 

Leukemia,  105,  109 

Leukemia  differentiated  from  pseu- 
do-leukemia, 111 

lieukocythemia,  105,  109 

Leukocytosis,  108 

Leukoplakia  lingualis  s.  buccalis, 
202 

Lipuria,  279 

Lithemia,  101 

Lithemia,  diagnosis  of,  101 

Liver,  244 

Liver,  abscess  of,  168,  250 

Liver,  actinomycosis  of,  251 

Liver,  amyloid  disease  of,  254 

Liver,  atrophy  of,  acute  yellow, 
248 

Liver,  carcinoma  of,  254 

Liver,  cirrhosis  of,  252 

Liver,  congestion  of,  246 

Liver,  fatty,  253 

Liver,  floating,  245 

Liver,  hydatid  cyst  of,  167,  256 

Liver,  malignant  disease  of,  differ- 
entiated from  chronic  peritonitis, 
244 

Lobar  pneumonia,  176 

Lobular  pneumonia,  175 

Local  asphyxia,  144 

Local  gangrene,  144 

Local  symptoms,  19 

Locomotor  ataxia,  327 

Lumbago,  93 

Lumbar  pachymeningitis,  328 

Lumbricoid  worms,  237 

Lung-fever,  176 

Lungs,  new-growths  in,  199 

Lymphadenoma,  111 

Lymphatic  anemia,  111 

Lymph-glands,  tuberculosis  of.  111 


Lymphoma,  malignant.  111 
Lyssophobia,  360 

Major  epilepsy,  370 

Malaria,  masked,  59 

Malarial  cachexia,  58 

Malarial    cachexia    differentiated 

from  acute  hepatitis,  244 
Malarial  diseases,  54 
Malarial  fever  differentiated  from — 

catarrhal  jaundice,  260 

Malta  fever,  62 

pulmonary  tuberculosis,  191 

syphilitic  fever,  61 

the  fever  of  suppuration  or  of 
septic  infection,  59 

typhoid  fever,  61 
Malarial  fever,  hemorrhagic,  58 
Malarial  fever,  hemorrhagic,  differ- 
entiated from — 

paroxysmal  hemoglobinuria,  60 

yellow  fever,  65 
Malarial  fever,  pernicious,  58 
Malarial    fever,    pernicious,     diag- 
nosis of,  60 
Malarial  fever,  varieties  of,  55 
Malarial  hematuria,  281 
Malarial  intermittent  fever,  56 
Malarial  intermittent  fever  differ- 
entiated from  hepatic   intermit- 
tent fever,  262 
Malarial  paroxysm,  56 
Malarial  remittent  fever,  57 
Malarial  remittent  fever  differenti- 
ated from  yellow  fever,  65 
Malformation  of  the  heart,  124 
Malignant    disease    differentiated 

from  catarrhal  jaundice,  260 
Malignant  disease  of  the  kidney,  297 
Malignant  disease  of  the  liver,  244 
Malignant  endocarditis,  139 
Malignant  lymphoma.  111 
Malignant  pustule,  89 
Malignant  smallpox,  77 
Mania,  acute,  differentiated  from — 

cerebral  meningitis,  344 

delirium  tremens,  363 
Masked  malaria,  59 
Malta  fever,  61 
Malta  fever  differentiated  from— 

malarial  fever,  62 

typhoid  fever,  62 
Measles,  69 

Measles  differentiated  from  chicken- 
pox,  80 


406 


IND  EX. 


Measles  differentiated  from — 
purpura,  115 
rubella,  75 
scarlet  fever,  73 
smallpox,  78 
typhus  fever,  70 
Measles,  French,  74 
Measles,  German,  74 
Mediastinum,  abscess  of,  142 
Mediastinum,  abscess  of,  differenti- 
ated from  aneurism  of  the  aorta, 
144 
Mediastinum,  diseases  of,  141 
Mediate  percussion,  161 
Mediterranean  fever,  61 
Megagastria,  218 
Megalocytes,  105 
Membranes,     spinal,     hemorrhage 

into,  314 
Membranous  croup,  155 
Membranous  enteritis,  224 
Membranous  sore-throat,  common, 

208 
Meniere's  disease,  381 
Meningitis,    acute,    differentiated 
from — 
hysteria,  375 
sunstroke,  362 
Meningitis,  cerebral,  342 
Meningitis,  cerebral,  differentiated 
from — 
acute  general  disease,  343 
acute  mania,  344 
cerebral  abscess,  350 
cerebritis,  349 
cerebro-spinal  fever,  344 
delirium  tremens,  363 
Meningitis,  cerebral,  simple,  differ- 
entiated from  tuberculous  menin- 
gitis, 343 
Meningitis,  epidemic  cerebro-spinal, 

46 
Meningitis,  spinal.  312 
Meningitis,  spinal,  acute,  differenti- 
ated from — 
acute  myelitis,  314 
tetanus,  378 
Meningitis,  spinal,  differentiated 
from — 
hemorrhage   into  the  spinal 

meninges,  314 
rheumatism  of  the  muscles  of 

the  back,  313 
spinal  hemorrhage,  335 
Meningitis,  tuberculous,  differenti- 


ated from  simple  cerebral  menin- 
gitis, 343 

Mensuration,  160 

Mercurial  stomatitis,  201 

Merycism,  214 

Mesenteric  vessels,  occlusion  of,  240 

Microcytes,  105 

Migraine,  311 

Migraine  differentiated  from  ordi- 
nary headache,  312 

Miliaria,  82 

Miliary  fever,  82 

Miliary  tuberculosis,  acute,  191 

Milk-sickness,  91 

Minor  epilepsy,  370 

Mitral  incompetency  or  regurgita- 
tion, 132 

Mitral  obstruction,  132 

Mollities  ossium,  118 

Mollities  ossium  differentiated  from 
rachitis,  118 

Monoplegia,  299,  300 

Moore's  test  for  the  presence  of  sugar 
in  the  urine,  285 

Morbilli,  69 

Morvan's  disease,  340 

Morvan's  disease  differentiated 
from — 
anesthetic  leprosy,  341 
diabetes,  342 
Raynaud's  disease,  341 
scleroderma,  340 
syphilis,  341 

Motion,  299 

Motor  activity  of  the  stomach,  214 

Mouth,  199 

Movable  kidney,  291 

Mucous  colic,  224 

Mucous  enteritis,  223 

Muguet,  200 

Multiple  neuritis,  303 

Multiple  sclerosis,  332 

Mumps,  204 

Murmurs,  endocardial,  136 

Murmurs,  organic,  differentiated 
from  functional  heart-murmurs, 
124 

Muscular  atrophy,  arthritic,  326 

Muscular  atrophy,  progressive,  320, 
321 

Muscular  atrophy,  progressive  neu- 
ral, 323 

Muscular  dystrophy,  progressive, 
324 

Muscular  rheumatism,  99 


INDEX. 


407 


Musculo-spiral  nerve,  paralysis  of, 

309 
Musculo-spiral    neuritis    differenti- 
ated  from  the  neuritis  of  lead- 
poisoning,  309 
Myalgia,  9S 
Myelitis,  315 

Myelitis,   acute,   differentiated 
from — 

acute     anterior    poliomyelitis, 
318 

acute  ascending  paralysis,  319 

acute  spinal  meningitis,  316 

chronic  myelitis,  317 

hysterical  paraplegia,  375 

multiple  neuritis,  304 

spinal  hemorrhage,  316 
Myelitis,  chronic,  316 
Myelitis,  chronic,  differentiated 
from — 

acute  myelitis,  317 

compression  of  the  cord,  337 

lateral  sclerosis,  317 

primary  lateral  sclerosis,  329 

progressive  muscular  atrophy, 
317 

spinal  pachymeningitis,  317 

syringomyelia,  339 

tumor  of  the  spinal  cord,  338 
Myocardium,  diseases  of,  138 
Myotonia  congenita,  327 
Myxedema,  385 
Myxedema  differentiated  from — 

adiposis,  387 

akromegaly,  389 

obesity,  387 

scleroderma,  386 

Nasal  catarrh,  acute,  148 

Nasal  respiration,  difficulty  of,  147 

Nasal  septum,  ulceration  or  erosion 

of,  148 
Neapolitan  fever,  61 
Negative  signs,  23 
Neoplasms,  laryngeal,  158 
Neoplasms  of  the  bladder,  289 
Nephritis,  acute,  292 
Nephritis     chronic,    differentiated 

from  cerebral  tumor,  358 
Nephritis,  chronic  interstitial,  293 
Nephritis,  chronic  interstitial,  dif- 
ferentiated from  diabetes   insip- 
idus, 283 
Nephritis,  chronic  parenchymatous, 
292 


Nephritis  differentiated  from  cysti- 
tis, 288 

Nervous  anorexia,  214 

Nervous  eructations,  214 

Nervous  vomiting,  214 

Neural  muscular  atroj^hy,  progres- 
sive, 323 

Neuralgia,  310 

Neuralgia  differentiated  from — 
neuritis,  303,  310 
subacute  rheumatism,  98 

Neuralgia,    intercostal,    differenti- 
ated from — 
acute  pleurisy,  167 
angina  pectoris,  128 

Neuralgia  of  the  stomach,  215 

Neuralgia,  rheumatic,  99 

Neuralgia,     sciatic,     differentiated 
from  sciatica,  305 

Neuralgia,  trifacial   or  trigeminal, 
311 

Neurasthenia,  375 

Neurasthenia    differentiated    from 
hysteria,  376 

Neuritis,  302 

Neuritis,  diagnosis  of,  303 

Neuritis  differentiated  from — 
disease  of  bone,  203 
neuralgia,  303,  310 
subacute  rheumatism,  303 

Neuritis,  multiple  or  disseminated, 
303 

Neuritis,     multiple,    differentiated 
from — 
acute  anterior  poliomyelitis,  319 
acute  ascending  paralysis,  319 
acute  myelitis,  304 
posterior  spinal  sclerosis,  328 
spinal  pachymeningitis,  304 

Neuritis,  musculo-spiral,  809 

Neuromata,  310 

Neuromata,  diagnosis  of,  310 

Neuroses  of  the  stomach, '214 

New-growths  in  the  lungs,  199 

Nigrities,  203 

Noma,  201 

Nutrition,  alterations  in,  in  disease 
of  the  nervous  system,  301 

Obesity,  387 
Objective  symptoms,  17 
Observation,  24 
Obstruction,  aortic,  133 
Obstruction,  intestinal,  231 
Obstruction,  intestinal,  acute,  dif- 


408 


INDEX. 


ferentiated  from  acute  peritonitis, 
242 

Obstruction,  intestinal,  differenti- 
ated from  acute  gastritis,  216 

Obstruction,  mitral,  132 

Obstruction  of  the  air-passages, 
155 

Obstruction  of  the  bowel  differenti- 
ated from  intussusception,  233 

Obstruction,  pulmonary,  135 

Obstruction,  tricuspid,  135 

Occlusion  of  the  biliary  passages 
differentiated  from  abscess  of  the 
liver,  251 

Occlusion  of  the  mesenteric  vessels, 
240 

Occupation-neuroses,  366 

Odor  of  urine,  268 

Oligemia,  105 

Oligochromemia,  105 

Oligocythemia,  105 

Omentum,  carcinoma  of,  222,  255 

Omentum,  sarcoma  of,  222 

Opisthotonos,  377 

Opium-poisoning  differentiated 

from  cerebral  hemorrhage,  353 

Organic  heart-murmurs,  124 

Organic  stricture  of  the  esophagus, 
212 

Orthotonos,  377 

Osteitis  deformans,  389 

Osteo-arthropathy,  hypertrophic, 
pulmonary,  391 

Ovary,  right,  abscess  of,  230 

Oxaluria,  273 

Oxyuris  vermicularis,  239 

Pachymeningitis,    cerebral,    342, 

343 
Pachymeningitis,  cervical,  313 
Pachymeningitis,  cervical,  differen- 
tiated from — 
progressive  muscular  atrophy, 

313 
subacute  anterior  poliomyelitis, 
313 
Pachymeningitis,  hemorrhagic,  342, 

343 
Pachymeningitis,  hypertrophic,  dif- 
ferentiated from — 
syringomyelia,  339 
tumor  of  the  spinal  cord,  338 
Pachymeningitis,  lumbar,  differen- 
tiated from  posterior  spinal  scle- 
rosis, 328 


Pachymeningitis,  spinal,  differenti- 
ated from — 
chronic  myelitis,  317 
multiple  neuritis,  304 
Paget's  disease,  389 
Palpation,  119,  160 
Palsy,  bulbar,  acute,  323 
Palsy,  bulbar,  acute,  distinguished 

from  chronic  bulbar  palsy,  323 
Palsy,   bulbar,   differentiated    from 

pseudo-bulbar  palsy,  324 
Palsy,  pseudo-bulbar,  324 
Palsy,  pseudo-bulbar,  differentiated 

from  true  bulbar  palsy,  324 
Palsy,  shaking,  333 
Paludism,  larval,  59 
Panaris,  analgesic,  340 
Pancreas,  265 

Pancreas,  carcinoma  of,  222,  265 
Pancreatic  cyst,  266 
Pancreatic  hemorrhage,  266 
Pancreatitis,  acute,  265 
Paralysis,  299 
Paralysis  agitans,  333 
Paralysis      agitans      differentiated 

from  cerebro-spinal  sclerosis,  334 
Paralysis,  ascending,  acute,  319 
Paralysis,  ascending,  acute,   differ- 
entiated from — 
acute  anterior  poliomyelitis,320 
acute  myelitis,  319 
multiple  neuritis,  319 
Paralysis,  asthenic,  bulbar,  324 
Paralysis,  bulbar,  progressive,  321 
Paralysis,    cerebral,    differentiated 

from  acute  anterior  poliomyelitis, 

318 
Paralysis,  family  periodic,  377 
Paralysis,  general,  of  the  insane,  359 
Paralysis,  general,  of  the  insane,  dif- 
ferentiated from  posterior  spinal 

sclerosis,  360 
Paralysis,       glosso-labio-laryngeal, 

320,  321 
Paralysis,  hysterical,  374 
Paralysis,  Landry's,  319 
Paralysis  of  the  diaphragm  differ- 
entiated from — 
asthma,  198 

paralysis  of  the  phrenic  nerve, 
309  ^ 

Paralysis  of  the  facial  nerve,  306 
Paralysis     of     the    musculo-spiral 

nerve,  309 
Paralysis  of  the  phrenic  nerve,  308 


INDEX. 


409 


Paralysis,  pseudo-hypertrophic,  dif- 
ferentiated from  congenital  spas- 
tic paraplegia,  347 

Paraplegia,  299,  300 

Paraplegia,  ataxic,  330 

Paraplegia,  ataxic,  hereditary,  331 

Paraplegia,  ataxic,  hereditary,  dif- 
ferentiated from  postero-lateral 
sclerosis,  331 

Paraplegia,  hysterical,  375 

Paraplegia,  spastic,  329 

Paraplegia,  spastic,  congenital,  346 

Paraplegia,  spastic,  congenital,  dif- 
ferentiated from  pseudo-hyper- 
trophic paralysis,  347 

Paraplegia,  spastic,  differentiated 
from  hysterical  paraplegia,  375 

Parasites,  intestinal,  234 

Parasitic  stomatitis,  200 

Parenchymatous  tonsillitis,  206 

Paresis,  299 

Paresthesia,  300 

Paretic  dementia,  359 

Parkinson's  disease,  333 

Parotiditis,  204 

Parotiditis  differentiated  from  lar- 
yngitis, 150 

Paroxysmal  hemoglobinuria,  281 

Paroxysmal  hemoglobinuria,  difl'er- 
entiated  from  hemorrhagic  mala- 
rial fever,  60 

Pathological  association,  diagnosis 
by  the  method  of,  20 

Pectoriloquy,  164 

Pectoriloquy,  "whispering,  164 

Pepsin  in  gastric  contents,  213 

Percussion,  119,  161 

Percussion,  auscultatory,  162 

Percussion,  immediate,  161 

Percussion,  mediate,  161 

Percussion,  respiratory,  162 

Perforation  of  the  bowel  in  typhoid 
fever,  40 

Pericardial    effusion   differentiated 
from — 
dilatation  of  the  heart,  130 
pericarditic  effusion,  140 
pleural  effusion,  169 

Pericarditis,  acute,  135 

Pericarditis,    acute,    differentiated 
from — 
acute  endocarditis,  140 
acute  pleurisy,  137 

Perihepatitis,  258 

Perihepatitis,    chronic,    differenti- 


ated from  cirrhosis  of  the  liver, 
258 
Perinephric  abscess,  296 
Periodic  paralysis,  family,  377 
Periodic  vasomotor  coryza,  149 
Peristaltic  unrest,  214 
Peritonitis,  acute,  241 
Peritonitis,     acute,     differentiated 
from — 
acute  enteritis,  242 
acute  gastritis,  241 
acute  intestinal  obstruction,  242 
intestinal  colic,  242 
subacute  rheumatism,  243 
Peritonitis,  chronic,  243 
Peritonitis,  chronic,  differentiated 
from    malignant   disease   of   the 
liver,  244 
Perityphlitis,  229 
Perityphlitis,  differential  diagnosis 

of,  230 
Perityphlitis  differentiated  from — 
abscess  of  the  right  ovary,  230 
carcinoma  of  the  cecum,  231 
lumbar  abscess,  230 
Pernicious  anemia,  107 
Pernicious  malarial  fever,  58 
Pernicious  malarial  fever,  diagnosis 

of,  58 
Pertussis,  157 
Petit  mal,  370 
Pharyngitis,  204 
Pharyngitis,  acute  catarrhal,  204 
Pharyngitis,    acute     phlegmonous, 

204 
Pharyngitis,  acute  tuberculous,  205 
Pharyngitis,  chronic,  205 
Pharyngitis      differentiated     from 

laryngitis,  150 
Pharyngitis,  gangrenous,  209 
Pharyngitis,  tuberculous,  differen- 
tiated from — 
syphilitic  sore-throat,  206 
typhoid  fever,  206 
Pharyngoscopy,  147 
Pharynx,  204 
Pharynx,  herpes  of,  208 
Phlebitis,  portal,  differentiated  from 

acute  hepatitis,  247 
Phlegmonous    pharvngitis,    acute, 

204 
Phosphoric  acid  in  urine,  270 
Phosphorus-poisoning       differenti- 
ated from  acute  yellow  atrophy 
of  the  liver,  249 


410 


INDEX. 


Phreuic  nerve,  paralysis  of,  308 

Phrenic  nerve,  paralysis  of,  differ- 
entiated from — 
defeneration  of  the  diaphragm, 

308 
inflammation  of  the  diaphragm, 

308 
superior  intercostal  breathing, 
308 

Phthisis,  fibroid,  183 

Phthisis,  florid,  183,  188 

Physical  diagnosis,  159 

Physical  signs,  18 

Pia-arachnitis,  342 

Plague,  bubonic,  62 

Plague  difterentiated  from — 
typhus  fever,  63 
yellow  fever,  63 

Plastic  bronchitis,  172 

Pleural  efi'usion,  169,  195,  197 

Pleurisy,  acute,  165 

Pleurisy,  acute,  differentiated 
from — 
acute  pericarditis,  137 
acute  pneumonia,  167 
intercostal  neuralgia,  167 

Pleurisy,  chronic,  170 

Pleurisy,  chronic,   differentiated 
from — 
interstitial  pneumonitis,  193 
intrathoracic  tumor,  170 
pulmonary  tuberculosis,  189 

Pleurisy  differentiated  from  perni- 
cious malarial  fever,  60 

Pleurisy,   pulsating,   differentiated 
from  thoracic  aneurism,  143 

Pleuritic  effusion,  167,  168,  169 

Pleuritic   effusion   differentiated 
from — 
abscess  of  liver,  168 
abscess  of  spleen,  168 
hydatid  cyst  of  liver,  167 
hydrothorax,  169 

Pleurosthotonos,  377 

Plumbism,  364 

Pneumonia,  acute  croupous  or  lobar, 
176 

Pneumonia,  catarrhal,  175 

Pneumonia,    catarrhal,    differenti- 
ated from — 
atelectasis,  176 
bronchiectasis,  173 
capillary  bronchitis,  175 
croupous  pneumonia,  180 
pulmonary  infarction,  176 


Pneumonia,  croupous,  differentiated 
from — 
acute  pleurisy,  167 
catarrhal  pneumonia,  180 
pulmonary  congestion,  180 
pulmonary  edema,  179 
pulmonary  infarction,  180 
pulmonary  tuberculosis,  181 

Pneumonia  differentiated  from — 
pernicious  malarial  fever,  60 
typhoid  fever,  43 

Pneumonia,  lobular,  175 

Pneumonitis,  interstitial,  193 

Pneumonitis,  interstitial,  differen- 
tiated from — 
chronic  bronchitis,  172 
chronic  pleurisy,  193 

Pneumothorax,  195 

Pneumothorax  differentiated 
from — 
diaphragmatic  hernia,  196 
pleural  effusion,  197 
pulmonary  cavity,  196 
pulmonary  emphysema,  194 
subphrenic  abscess,  197 

Poikilocytes,  105 

Poisoning,  arsenical,  52 

Poisoning,  narcotic,  differentiated 
from  sunstroke,  362 

Poliomyelitis,        anterior,      acute, 
318 

Poliomyelitis,  anterior,  acute,  dif- 
ferentiated from — 
acute  ascending  paralysis,  320 
acute  myelitis,  318 
cerebral  paralysis,  318 
multiple  neuritis,  319 
progressive  muscular  atrophy, 
323 

Poliomyelitis,  anterior,  subacute, 
differentiated  from  cervical 
pachymeningitis,  313 

Polyneuritis,  303 

Polyuria,  282 

Polyuria,  hysterical,  differentiated 
from  diabetes  insipidus,  283 

Portal  phlebitis,  247 

Posterior  spinal  sclerosis,  327 

Postero-lateral  sclerosis,  330 

Previous  history,  19 

Primary  lateral  sclerosis,  329 

Primary  sciatica,  306 

Progressive  bulbar  paralysis,  321 

Progressive  muscular  atrophy,  320, 
321 


INDEX 


411 


Progressive    muscular    dystrophy, 
324 

Progressive  ueural  muscular  atro- 
phy. 323 

Progressive  paralysis  of  the  insane, 
359 

Pseudo-bulbar  palsy,  324 

Pseudo-hydropliobia,  380 

Pseudo-leukemia.  121 

Pseudo-leukemia  ditlereutiated 
from — 
leukemia,  111 

tuberculosis     of     the     lymph- 
glands,  112 

Pseudo-leukemic  anemia,  infantile, 
112 

Pseudo-membranous  laryngitis,  155 

Pulmonarv  abscess,    173,    181,   182, 
191 

Pulmonary  carcinoma,  189 

Pulmonary  cavity,  196 

Pulmonary  congestion,  180 

Pulmonary  edema.  179 

Pulmonary  emphysema,  194 

Pulmonary  gangrene,  182 

Pulmonary  hemorrhage,  189 

Pulmonary   hypertrophic   osteo-ar- 
thropathy,  391 

Pulmonary  incompetency  or  regur- 
gitation, 135 

Pulmonary  infarction,  176,  180 

Pulmonary  obstruction,  135 

Pulmonary  syphilis,  190 

Pulmonary  tuberculosis,  182 

Pulsating  pleurisy,  143 

Pulsatory  empyema,  166 

Purity  of  the  heart-sounds,  121 

Purpura,  114 

Purpura  differentiated  from — 
measles,  115 
scorbutus,  115 

Purring  tremor,  119 

Putrid  bronchitis.  172 

Putrid  sore-throat,  209 

Pyelitis.  274,  289 

Pyelitis  differentiated  from  cvstitis, 
289 

Pyemia  differentiated  from — 
acute  rheumatism,  96 
typhoid  fever,  41 

Pylephlebitis    differentiated    from 
catarrhal  jaundice.  260 

Pylorus,  insufficiency  of,  214 

Pylorus,  spasm  of,  214 

Pyonephrosis,  298 


Pyrexia,  27 
Pyuria,  274 

Quantity  of  urine,  267 
Quinsy,  206 

Eachitis,  117 

Rachitis   differentiated   from    mol- 

lities  ossium,  118 
Eag-weed  fever,  149 
Eaies,  63 

Rational  signs,  19 
Raynaud's  disease,  144 
Eaynaud's     disease     differentiated 
from — 
frost-bite,  145 
Morvan's  disease,  341 
Reaction  of  degeneration,  301 
Eeaction  of  urine,  26S 
Eecrudescencein  typhoid  fever,  39 
Recurrent    herpes    of   the   throat, 

208 
Reflex  svmptoms,  19 
Reflexes,  300 
Reflexes,  alterations  in,  in  disease, 

301 
Reflexes,  deep,  301 
Reflexes,  superficial,  300 
Regurgitation,  aortic,  133 
Regurgitation,  mitral,  132 
Regurgitation,  pulmonary,  135 
Regurgitation,   tricuspid,  134 
Relapse  in  typhoid  fever,  39 
Relapsing  fever,  52 
Relapsing   fever    differentiated 
from — 
typhoid  fever,  53 
typhus  fever,  52 
yellow  fever,  53 
Remittent  fever.  30 
Remittent  fever,  malarial,  57 
Renal  calculus,  291 
Renal  colic,  262 
Renal  inadequacy,  290 
Rennet-ferment  in  sastric  contents, 

213 
Resonance,  vocal,  164 
Respiratory  percussion,  162 
Respiratory  system.  146 
Retro-pharyngeal  abscess,  156,  210 
Rheumatic  fever,  95 
Rheumatic  neuralgia,  99 
Rheumatism,  acute,  95 
Rheumatism,  acute,  differentiated, 

from  acute  gout,  100 


412 


INDEX 


Rheumatism,  acute,    differentiated 
from 

acute  synovitis,  97 

pyemia,  96 
Rheumatism,  chronic,  99 
Rheumatism,  chronic,  differentiated 
from — 

chronic  spinal  disease,  99 

rheumatoid  arthritis,  103 
Rheumatism,  muscular,  99 
Rheumatism  of  the  muscles  of  the 
back   differentiated   from    spinal 
meningitis,  313 
Rheumatism,  subacute,  98 
Rheumatism,   subacute,    differenti- 
ated from — 

acute  peritonitis,  243 

neuralgia,  98 

neuritis,  303 

trichiniasis,  98 
Rheumatoid  arthritis,  102 
Rheumatoid  arthritis  differentiated 
from — 

chronic  rheumatism,  103 

gout,  104 
Rhinoscopy,  146 
Rhizomelic  spondylosis,  392 
Risus  sardonicus,  377 
Rock  fever,  61 
Rose-cold,  149 
Roseola,  74 
Rotheln,  74 
Round-worms,  237 
Rubella,  74 

Rubella  differentiated  from — 
„   morbilli,  75 

scarlatina,  75 
Rumination,  214 

Sarcoma  of  the  omentum  differen- 
tiated   from    carcinoma    of    the 
stomach,  222 
Scarlatina,  70 
Scarlet  fever,  70 
Scarlet  fever  differentiated  from — 

acute  exfoliative  dermatitis,  73 

dengue,  84 

diphtheria,  86 

erysipelas,  81 

measles,  73 

rubella,  75 

smallpox,  78 

toxic  dermatitis,  73 
Sciatic  neuralgia,  305 
Sciatica,  305 


Sciatica  differentiated  from — 
disease  of  the  hip-joint,  305 
sciatic  neuralgia,  305 

Sciatica,      primary,     differentiated 
from  secondary  sciatica,  306 

Sciatica,    secondary,   differentiated 
from  primary  sciatica,  306 

Sclerodactyly,  340 

Scleroderma  differentiated  from — 
Morvan's  disease,  340 
myxedema,  386 

Sclerosis,  cerebro-spinal,  332 

Sclerosis,  cerebro-spinal,  differenti- 
ated from — 
cerebral  tumor,  358 
paralysis  agitans,  334 
postero-lateral  sclerosis,  332 

Sclerosis,  disseminated,  332 

Sclerosis,  insular,  332 

Sclerosis,  lateral,  amyotrophic,  320, 
321 

Sclerosis,  lateral,  differentiated  from 
chronic  myelitis,  317 

Sclerosis,  lateral,  primary,  329 

Sclerosis,  lateral,  primary,  differen- 
tiated from — 
cerebral  hemiplegia,  330 
chronic  myelitis,  329 
postero-lateral  sclerosis,  331 

Sclerosis,  multiple,  332 

Sclerosis,  postero-lateral,  330 

Sclerosis,  postero-lateral,  differenti- 
tiated  from — 
cerebellar  tumor,  331 
cerebro-spinal  sclerosis,  332 
hereditary    ataxic    paraplegia, 

331 
posterior  spinal  sclerosis,  330 
primary  lateral  sclerosis,  330 

Sclerosis,  spinal,  posterior,  327 

Sclerosis,  spinal,  posterior,  differen- 
tiated from — 
cerebellar  tumor,  329 
general  paralysis  of  the  insane, 

360 
lumbar  pachymeningitis,  328 
multiple  neuritis,  328 
postero-lateral  sclerosis,  330 

Scorbutus,  113 

Scorbutus  differentiated  from  pur- 
pura, 115 

Scurvy,  113 

Seat-worms,  239 

Secondary  sciatica,  306 

Sensation,  300 


INDEX 


413 


Septic  infection,  fever  of,  differenti- 
ated from  nuilurial  fever,  59 
Sequela?,  22 
Shaking  palsy,  333 
Sliip-fever,  44 
Sick  headache,  311 
Signs,  18 

Signs,  instrumental,  18 
Signs,  negative,  23 
Signs,  physical,  18 
Signs,  rational,  19 
Simple  continued  fever,  31 
Simple  endocarditis,  139 
Smallpox,  75 
Smallpox,  confluent,  76 
Smallpox  differentiated  from^ — 

cerebro-spinal  fever,  49 

cliickenpox,  79 

erysipelas,  82 

glanders,  88 

measles,  78 

scarlet  fever,  78 

typhoid  fever,  42 

typhus  fever,  45 
Smallpox,  discrete,  76 
Smallpox,  hemorrhagic,  77 
Smallpox,  malignant,  77 
Smallpox,  varieties  of,  76 
Sodium  chloride  in  urine,  269 
Softening,  cerebral,  354 
Sore-throat,  common  memhranous, 

208 
Sore-throat,  common  memhranous, 
differentiated     from    diphtheria, 
209 
Sore-throat,  gangrenous,  differenti- 
ated from  diphtheria,  209 
Sore-throat,  herpetic,  208 
Sore-throat,  putrid,  209 
Sore-throat,    syphilitic,    differenti- 
ated from  tuberculous  pharyngi- 
tis, 206 
Spasm,  300 

Spasm  of  the  cardia,  214 
Spasm  of  the  pylorus,  214 
Spasmodic  croup,  154 
Spasmodic  tic,  369 
Spastic  paraplegia,  329 
Spastic  paraplegia,  congenital,  346 
Specific  fever,  30 
Specific  gravity  of  urine,  268 
Sphygmogram,  124 
Sphygmograph,  124 
Spinal  compression,  336 
Spinal  disease,  chronic,  differenti- 


ated from  chronic  rheumatism, 
99 

Spinal  hemorrhage,  335 

Spinal  membraneSjhemorrhage  into, 
314 

Spinal  meningitis,  312 

Spinal  pachymeningitis,  304,  317 

Spinal  tumor,  337 

Splanchnoptosis,  215 

Spleen,  263 

Spleen,  abscess  of,  68 

Spleen,  enlargement  of,  264 

Spleen,  floating,  264 

Splenic  fever,  89 

Splenic  tumor,  264 

Splenitis,  264 

Splenomegaly,  265 

Spondylosis,  rhizomelic,  392 

Spool-worms,  239 

Sporadic  cretinism,  385 

Sporadic  cretiuoidism,  385 

Spotted  fever,  47 

Sputum,  tubercle-bacilli  in,  186 

Status  epilepticus,  371 

Stomach,  212 

Stomach,  atony  of,  214 

Stomach,  digestive  activity  of,  213 

Stomach,  dilatation  of,  218 

Stomach,  functions  of,  213 

Stomach,  hyperesthesia  of,  214 

Stomach,  motor  activity  of,  214 

Stomach,  neuralgia  of,  215 

Stomach,  neuroses  of,  214 

Stomatitis,  aphthous,  200 

Stomatitis,  catarrhal,  199 

Stomatitis  differentiated  from  diph- 
theria, 87 

Stomatitis,  gangrenous,  201 

Stomatitis,  mercurial,  201 

Stomatitis,  parasitic,  200 

Stomatitis,  ulcerative,  200 

Stricture,  functional,  of  the  esopha- 
gus differentiated  from  organic 
stricture,  212 

Stricture  of  the  esophagus.  211 

Strychnine-poisoning  diflerentiated 
from  tetanus,  378 

Subacidity,  215 

Subacute  rheumatism,  98 

Subfebrile  temperature,  28 

Subjective  symptoms,  17 

Subnormal  temperature,  29 

Subphrenic  abscess,  197 

Sugar  in  the  urine,  Boettger's  test 
for  the  presence  of,  285 


414 


INDEX 


Su^ar  in  the  urine,  Fehling's  test 

for  the  presence  of,  286 
Sugar  in  the  urine,  fermentation- 
test  for  the  presence  of,  286 
Sugar  in  tlie  urine,  Moore's  test  for 

the  presence  of,  285 
Sugar  in  the  urine,  Trommer's  test 

for  the  presence  of,  286 
Sulphuric  acid  in  urine,  271 
Sun -pain,  59 
Sunstroke,  361 

Sunstroke  differentiated  from — 
acute  alcoholism,  362 
acute  meningitis,  362 
cerebral  hemorrhage,  362 
heat-exhaustion,  362 
narcotic  poisoning,  362 
uremia,  295,  362 
Superficial  reflexes,  273 
Supermotility,  214 
Supersecretion,  215 
Suppuration,  fever  of,  differentiated 

from  malarial  fever,  59 
Suprarenal  bodies,  tuberculosis  of, 

116 
Sweating  disease,  82 
Symmetrical  gangrene,  144 
Symptomatic  fever,  30 
Symptoms,  17 

Symptoms,  constitutional,  19 
Symptoms,  general,  19 
Symptoms,  local,  19 
Symptoms,  objective,  17 
Symptoms,  reflex,  19 
Symptoms,  subjective,  17 
Syncope  differentiated  from — 
cerebral  hemorrhage,  353 
epilepsy,  371 
Syncope,  local,  144 
Synovitis,      acute,      differentiated 

from  acute  rheumatism,  97 
Synovitis,  gonorrheal,  97 
Syphilis  differentiated  from — 
glanders,  88 
Morvan's  disease,  341 
Syphilis,  pulmonary,  differentiated 

from      pulmonary     tuberculosis, 

190 
Syphilitic  arthritis,  97 
Syphilitic  fever  differentiated  from 

malarial  fever,  61 
Syphilitic  sore-throat,  206 
Syringomyelia,  33-9 
Syringomyelia   differentiated   from 

chronic  myelitis,  339 


Syringomyelia  differentiated  from — 
hypertrophic  pachymeningitis, 

339 
leprosy,  339 
progressive  muscular  atrophv, 

339 

Tabes  dorsalis,  327 

Tabes  mesenterica,  244 

Tachycardia,  126 

Tachycardia  differentiated  from — 

angina  pectoris,  126 

exophthalmic  goiter,  126 

irritable  heart,  127 
Tactile  fremitus,  160 
Taenia  mediocanellata,  236 
Tsenia  solium,  235 
Tape-worm,  235 
Temperature,  27 
Temperature,  febrile,  28 
Temperature,  inverse,  28 
Temperature,  subfebrile,  28 
Temperature,  subnormal,  29 
Temperature,  sudden  fall  of,  29 
Test-breakfast,  213 
Test-dinner,  213 
Tetanus,  377 
Tetanus  differentiated  from — 

acute  spinal  meningitis,  378 

cerebro-spinal  fever,  48 

hemorrhage    into     the     spinal 
membranes,  378 

hydrophobia,  381 

hysteria,  378 

strychnine-poisoning,  378 

tetanv,  379 
Tetany,  379 
Tetanv  differentiated  from  tetanus, 

379*^ 
Thermic  fever,  361 
Thomsen's  disease,  327 
Thoracic  aneurism,  141 
Thread-worms,  239 
Throat,  chronic  or  recurrent  herpes 

of,  208 
Throat,  diphtheroid,  208 
Thrombosis,  cerebral,  356 
Thrombosis,  cerebral,  differentiated 

from  cerebral  hemorrhage,  356 
Thrush,  200 
Tic  douloui'eux,  311 
Tic,  sjiasmodic,  369 
Tongue,  202 

Tongue,  black  or  hairy,  203 
Tongue  geographical,  203 


INDEX. 


415 


Tonsillitis,  206 
Tonsillitis,  chronic,  208 
Tonsillitis  differentiated  from — 
diphtheria,  86 
laryngitis,  150 
Tonsillitis,  herpetic,  208 
Tonsillitis,  lacunal  or  follicular,  207 
Tonsillitis,  jiarenchymatous,  206 
Topfer's  test  for  hj'drochloric  acid, 

212 
Torticollis,  98,  366 
Torticollis  differentiated  from  cere- 

bro- spinal  fever,  49 
Touch,  160 
Translumination,  146 
Transparency  of  urine,  267 
Tremor,  purring,  119 
Trichiniasis,  92,  234 
Trichiniasis  differentiated  from — 
subacute  rheumatism,  98 
typhoid  fever,  43 
Tricuspid  incompetency  or  regurgi- 
tation, 134 
Tricuspid  obstruction,  135 
Trifacial  neuralgia,  311 
Trigeminal  neuralgia,  311 
Trommer's  test  for  the  presence  of 

sugar  in  the  urine,  286 
Tube-casts  in  urine,  278 
Tubercle-bacilli  in  sputum,  186 
Tuberculosis,  acute  miliary,  191 
Tuberculosis,  acute  miliary,  differ- 
entiated from — 
acute  bronchitis,  171 
capillary  bronchitis,  174 
typhoid  fever,  192 
Tuberculosis,  chronic,  of  the  larynx, 

159 
Tuberculosis  of  the  bronchial  glands 
differentiated     from     whooping- 
cough,  158 
Tuberculosis  of  the  kidney,  296 
Tuberculosis  of  the  lymph-glands 
differentiated  from  pseudo-leuke- 
mia, 111 
Tuberculosis    of     the     suprarenal 

bodies,  116 
Tuberculosis,  pulmonary,  182 
Tuberculosis,  pulmonary,  differen- 
tiated from — 
bronchiectasis,  190 
chronic  bronchitis,  172 
chronic  pleurisy,  189 
croupous  pneumonia,  181 
malarial  fever,  191 


Tuberculosis,  pulmonary,  differen- 
tiated frtmi — 

pulmonary  abscess,  191 

pulmonary  cax'cinoma,  189 

pulmonary  gangrene,  182 

pulmonary  syphilis,  190 
Tuberculous  laryngitis,  acute,  152 
Tuberculous  meningitis,  343 
Tuberculous  ])haryngitis,  206 
Tuberculous  pharyngitis,  acute,  205 
Tubular  diarrhea,  224 
Tumor,    cerebellar,     differentiated 
from — 

posterior  spinal  sclerosis,  329 

postero-lateral  sclerosis,  331 
Tumor,  cerebral,  357 
Tumor,  cerebral,  differentiated 
from — 

anemia,  358 

cerebral  abscess,  350 

cerebro-spinal  sclerosis,  358 

chronic  nephritis,  358 

epilepsy,  358 

hysteria,  375 

lead-poisoning,  365 
Tumor,intra-thoracic,differentiated 
from — • 

aneurism  of  the  aorta,  142 

chronic  pleurisy,  170 
Tumor  of  the  spinal  cord,  337 
Tumor  of  the  spinal  cord  differen- 
tiated from — 

caries  of  the  vertebrae,  338 

chronic  myelitis,  338 

hypertrophic  pachymeningitis, 
'338 
Tumor,  splenic,  264 
Typhlitis,  228 
Tj'phlitis  differentiated  from — 

abscess  of  the  right  ovary,  230 

carcinoma  of  the  cecum,  231 

intussusception  of  bowel,  233 

lumbar  abscess,  230 
Typhoid    condition    differentiated 

from  typhoid  fever,  42 
Typhoid  fever,  35 
Typhoid  fever,  abortive,  39 
Tvphoid  fever,  ambulatory  or  walk- 
ing, 39 
Typhoid  fever  differentiated  from — 

acute  catarrhal  enteritis,  224 

acvite  dysentery,  227 

acute  miliary  tuberculosis.  192 

acute   yellow    atrophy   of    the 
liver,  249 


416 


INDEX. 


Typhoid  fever  diiferentiated  from — 

cerebro-spinal  fever,  50 

malarial  fever,  61 

Malta  fever,  62 

pneumonia,  43 

pyemia,  41 

relapsing  fever,  53 

trichiniasis,  43 

tuberculous  pharyngitis,  206 

typhoid  condition,  42 

typhus  fever,  45 

variola,  42 

yellow  fever,  42 
Typhoid   fever,   perforation  of  the 

bowel  in,  40 
Typhoid    fever,    recrudescence    in, 

40 
Typhoid  fever,  relapse  in,  39 
Typhus  fever,  44 
Typhus  fever  differentiated  from — 

cerebro-spinal  fever,  48 

morbilli,  70 

plague,  63 

relapsing  fever,  53 

typhoid  fever,  45 

variola,  45 
Tyrosin,  272 

Uffelmann's  test  for  lactic  acid, 
213 

Ulcer,  gastric,  218 

Ulcer,  gastric,  differentiated  from 
chronic  gastritis,  219 

Ulceration  of  the  stomach  differen- 
tiated from  carcinoma  of  the  stom- 
ach, 221 

Ulcerative  stomatitis,  200 

Ulcero-membranous  angina,  208 

Uudulant  fever,  61 

Unrest,  peristaltic,  214 

Urea  in  urine,  268 

Uremia,  293 

Uremia  differentiated  from — 
cerebral  hemorrhage,  354 
epilepsy,  294,  372 
sunstroke,  295,  362 

Ureteritis,  274 

Urethritis,  274 

Uric  acid  in  urine,  269 

Urine,  acetone  in,  tests  for  the  pres- 
ence of,  286 

Urine,  albumin  in,  275 

Urine,  biliary  acids  in,  271 

Urine,  biliary  coloring-matter  in, 
271 


Urine,  color  of,  267 

Urine,  constitution  of,  267 

Urine,  diacetic  acid  in,  tests  for  the 

presence  of,  287 
Urine,  examination  of,  267 
Urine,  hippuric  acid  in,  269 
Urine,  odor  of,  268 
Urine,  phosphoric  acid  in,  271 
Urine,  quantity  of,  267 
Urine,  reaction  of,  268 
Urine,  sodium  chloride  in,  269 
Urine,  specific  gravity  of,  268 
Urine,  sugar  in,  Boettger's  test  for 

the  presence  of,  285 
Urine,  sugar  in,  Fehling's  test  for 

the  presence  of,  286 
Urine,  sugar   in,  fermentation-test 

for  the  presence  of,  286 
Urine,  sugar  in,  Moore's  test  for  the 

presence  of,  285 
Urine,  sugar  in,  Trommer's  test  for 

the  presence  of,  286 
Urine,  sulphuric  acid  in,  271 
Urine,  transparency  of,  267 
Urine,  tube-casts  in,  278 
Urine,  urea  in,  268 
Urine,  uric  acid  in,  269 

Vaccination,  77 

Vaccinia,  78 

Valvular  disease  of  the  heart, 
131 

Valvular  disease  of  the  heart  differ- 
entiated from  acute  endocarditis, 
139 

Varicella,  79 

Variola,  75 

Varioloid,  77 

Varioloid  differentiated  from  chick- 
en pox,  79 

Vasomotor  ataxia,  384 

Vegetative  endocarditis,  139 

Vertebrae,  caries  of,  338 

Vertigo,  aural  381 

Vertigo,  aural,  differentiated  from 
epilepsy,  381 

Vertigo,  labyrinthine,  381 

Vertigo,  laryngeal,  153 

Vesical  calculus,  289 

Virus,  humanized,  77 

Vocal  fremitus,  160 

Vocal  resonance,  164 

Vomiting,  nervous,  214 

Walking  typhoid  fever,  139 


INDEX. 


417 


Waxy  casts  of  the  uriniferous  tub- 
ules, 278 

Waxy  kidney,  293 

Weil's  disease,  G7 

Weil's  disease  differentiated  from — 
catarrhal  jaundice,  200 
yellow  fever,  67 

Whispering  pectoriloquj-,  1G4 

Whooping-cough,  157 

Whooping-cough  differentiated 
from — 
asthma,  198 

laryngismus  stridulus,  157 
membranous  croup,  157 
tuberculosis    of    the   bronchial 
glands,  157 

Wool-sorters'  disease,  89 

27 


Writers'  cramp,  367 
Wry-neck,  98,  366 

Yellow  fever,  64 

Yellow  fever  differentiated  from — 

acute   yellow   atrophy    of    the 
liver,  66 

catarrhal  jaundice,  260 

cerebro-spinal  fever,  49 

dengue,  66 

hemorrhagic      malarial     fever, 
65 

malarial  remittent  fever,  65 

plague,  63 

relapsing  fever,  53 

typhoid  lever,  42 

Weil's  disease,  67 


Medical  and  Surgical  Works 


PUBLISHED   BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  PhiladelpMa,  Pa. 


PAGE 

Abbott  on  Transmissible  Diseases    .    .    .    .  i8 
American  Pocket  Medical  Dictionary    .    .  35 
*American  Text-Book  of   Applied   Thera- 
peutics     8 

*American  Text-Book  of  Dis.  of  Children  .  13 
*An  American  Text-Book  of  Diseases  of  the 

Eye,  Ear,  Nose,  and  Throat 15 

*An   American  Text-Book  of  Genito-Uri- 

nary  and  Skin  Diseases 14 

*American  Text-Book  of  Gynecology  .  .  .12 
*American  Text-Book  of  Legal  JNIedicine  .  44 
*American  Text-Book  of  Obstetrics  ...  9 
*American  Text-Book  of  Pathology  ...  44 
*American  Text-Book  of  Physiology  ...  7 
*American  Text-Book  of  Practice  ....  10 
♦American  Text-Book  of  Surgery  ...  11 
Anders'  Theory  and  Practice  of  iledicine  .  21 

Ashton's  Obstetrics 43 

Atlas  of  Skin  Diseases 28 

Ball's  Bacteriology 43 

Bastin's  Laboratory  Exercises  in  Botany  .  36 

Beck's  Surgical  Asepsis 41 

Boisliniere's  Obstetric  Accidents 39 

Brockway's  Physics 43 

Burr's  Nervous  Diseases 41 

Butler's  Materia  Medica  and  Therapeutics  24 
Cerna's  Notes  on  the  Newer  Remedies  .  .  32 
Chapin's  Compendium  of  Insanity  ....  35 
Chapman's  Medical  Jurisprudence  .  .  .  .  41 
Church  and  Peterson's  Nervous  and  Men- 
tal Diseases 17 

Ciarkson's  Histology 33 

Cohen  and  Eshner's  Diagnosis 43 

Corwin's  Diagnosis  of  the  Thorax   ....  37 

Cragin's  Gi'naecology 43 

Crookshanic's  Text-Book  of  Bacteriology  .  27 

DaCosta's  Manual  of  Surgery 23 

De  Schweinitz's  Diseases  of  the  Eye  ...  29 
Dorland's  Pocket  Medical  Dictionary   .    ,  35 

Dorland's  Obstetrics 41 

Frothingham's  Bacteriological  Guide  ...  30 

Garrigues'  Diseases  of  Women 34 

Gleason's  Diseases  of  the  Ear 43 

*Gould  and  Pyle's  Curiosities  of  Medicine  .  17 

Grafstrom's  Massage 28 

Griffith's  Care  of  the  Baby 38 

Griffith's  Infant's  Weight  Chart 39 

Gross's  Autobioeraphy 26 

Hampton's  Nursing 39 

Hare's  Physiology' 43 

Hart's  Diet  in  Sickness  and  in  Health    .    .  36 

Haynes'  Manual  of  Anatomy 41 

Heisler's  Embryology 19 

Hirst's  Obstetrics 20 

Hyde's  Syphilis  and  Venereal  Diseases  .  .  41 
International  Text-Book  of  Surgery    ...    6 

Jackson's  Diseases  of  the  Eye 19 

Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat 43 

Keating's  Pronouncing  Dictionary  ....  26 

Keating's  Life  Insurance 39 

Keen's  Operation  Blanks     . 36 

Keen's  Surgery  of  Typhoid  Fever  ....  22 


PAGE 

Kyle's  Diseases  of  Nose  and  Throat  ...  18 

Laine's  'i'emperature  Charts 32 

Levy  &  Klemperer's  Clinical  Bacteriology44 
Lockwood's  Practice  of  Medicine    .    .    .    .  41 

Long's  Syllabus  of  Gynecology 34 

Macdonald's  Surgical  Diagnosis  and  Treat- 
ment     22 

McFarland's  Pathogenic  Bacteria    ....  30 
Mallory  and  Wright's  Pathological  Tech- 
nique   22 

Martin's  Surgery 43 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 43 

Meigs'  Feeding  in  Early  Infancy 30 

JNIoore's  Orthopedic  Surgery 23 

Morris'  Materia  Medica  and  Therapeutics  43 

Morris'  Practice  of  Medicine 43 

Morten's  Nurses'  Dictionary' 38 

Nancrede's  Anatomy  and  Dissection  ...  31 

Nancrede's  Anatomy 43 

Nancrede's  Principles  of  Surgery  .  .  .  .19' 
Norris'  Syllabus  of  Obstetrical  Lectures    .  37 

Penrose's  Diseases  of  Women 24 

Powell's  Diseases  of  Children 43 

Pryor's  Pelvic  Inflammations 33 

Pye's  Bandaging  and  Surgical  Dressing    .  23 

Raymond's  Physiology 41 

Saundby's  Renal  and  tJrinary  Diseases  .    .  25 
*Saunders'  American  \'ear-Book  of  Medi- 
cine and  Surgery 16 

Saunders'  Medical  Hand-Atlases  .  .  .  3,  4,  5 
Saunders'  Pocket  ^ledical  Formulary  .  .  35 
Saunders'  New  Series  of  jManiials  .  .  .  40,  41 
Saunders'  Series  of  Question  Compends  42,  43 

Sayre's  Practice  of  Pharmacy- 43 

Semple's  Pathology'  and  Morbid  Anatomy  43 
Semple's  Legal  Medicine  and  1  oxicology.  43 
Senn's  Genito-Urinary  Tuberculosis  ...  24 

Senn's  Tumors 25 

Senn's  Syllabus  of  Lectures  on  Surgery  .  .  37 
Shaw's  Nervous  Diseases  and  Insanity  .    .  43 

Starr's  Diet-Lists  for  Children 38 

Stelwagon's  Diseases  of  the  Skin 43 

Stengel's  Pathology 20 

Stevens'  Materia  INIedica  and  Therapeutics  32 

Stevens'  Practice  of  ^Medicine 31 

Stewart's  Manual  of  Physiology' 37 

Stewart    and    Lawrance's    Medical    Elec- 
tricity      ^ 43 

Stoney's  Materia  jMedica  for  Nurses  ...  31 
Stoney's  Practical  Points  in  Nursing  ...  27 
Sutton  and  Giles'  Diseases  of  Women  .  29,  41 
Thomas's  Diet-List  and  Sick-Room  ...  38 
Thornton's  Dose-Book  and  Manual  of  Pre- 
scription-Writing     41 

Van  Valzah  and  Nisbet's  Diseases  of  the 

Stomach 21 

Vecki's  Sexual  Impotence 33 

Vierordt  and  Stuart's  Medical  Diagnosis  .  28 

Warren's  Surgical  Pathology 25 

Watson's  Handbook  for  Nurses 26 

Wolff's  Chemistry 43 

Wolff's  Examination  of  L^rine 43 


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SAU  NDERS' 

MEDICAL   HAND-ATLASES. 


The  series  of  books  included  under  this  title  consists  of  authorized  translations 
into  English  of  the  workl-famous  Lehmann  Medicinische  Handatlanten, 
which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheap- 
ness surpass  any  similar  volumes  ever  published.  Each  volume  contains  from 
50  to  100  colored  plates,  executed  by  the  most  skilful  German  lithographers, 
besides  numerous  illustrations  in  the  text.  There  is  a  full  and  appropriate  de- 
scription, and  each  book  contains  a  condensed  but  adequate  outline  of  the 
subject  to  which  it  is  devoted. 

In  planning  this  series  arrangements  were  made  with  representative  pub- 
lishers in  the  chief  medical  centers  of  the  world  for  the  publication  of  transla- 
tions of  the  atlases  into  nine  different' languages,  the  lithographic  plates  for  all 
being  made  in  Germany,  where  work  of  this  kind  has  been  brought  to  the  greatest 
perfection.  The  enormous  expense  of  making  the  plates  bemg  shared  by  the 
various  publishers,  the  cost  to  each  one  was  reduced  to  practically  one-tenth. 
Thus  by  reason  of  their  universal  translation  and  reproduction,  affording  in- 
ternational distribution,  the  publishers  have  been  enabled  to  secure  for  these 
atlases  the  best  artistic  and  professional  talent,  to  produce  them  in  the  most 
elegant  style,  and  yet  to  offer  them  at  a  price  heretofore  unapproached 
in  cheapness.  The  great  success  of  the  undertaking  is  demonstrated  by  the 
fact  that  the  volumes  have  already  appeared  in  thirteen  different  languages 
— German,  English,  French,  Italian,  Russian,  Spanish,  Japanese,  Dutch,  Danish, 
Swedish,  Roumanian,  Bohemian,  and  Hungarian. 

In  view  of  the  unprecedented  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hundred 
thousand  copies  of  the  atlases.  In  consideration  of  this  enormous  under- 
taking, the  pubHsher  has  been  enabled  to  prepare  and  furnish  special  additional 
colored  plates,  making  the  series  even  handsomer  and  more  complete  than 
was  originally  intended. 

As  an  indication  of  the  great  practical  value  of  the  atlases  and  of  the  im- 
mense favor  with  which  they  have  been  received,  it  should  be  noted  that  the 
Medical  Department  of  the  U.  S.  Army  has  adopted  the  "Atlas  of  Opera- 
tive Surgery,"'  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been  secured  in 
the  English  edition  as  in  the  originals.  The  translations  have  been  edited  by 
the  leading  American  specialists  in  the  different  subjects. 

i^For  List  of  Volumes  in  this  Series^  see  next  two  pages. ) 

3 


SAUNDERS'  MEDICAL  HAND-ATLASES. 


VOLUMES  NOW  READY, 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Kshnek,  ]\1.  I)., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  68  colored 
plates,  64  text-illustrations,  and  259  pages  of  text.     Cloth,  ^3.00  net. 

"  The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.  It  deals  with  facts.  It  vividly  illustrates  those  facts.  It  is  a  scientific  work 
put  together  for  ready  reference." — Brooklyn  Medical  Journal. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited 
by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Dept.,  College 
of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates,  and  193  beautiful  half-tone  illustrations.     Cloth,  ^3.50  net. 

"  Hofmann's  'Atlas  of  Legal  Medicine'  is  a  unique  work.  This  immense  field  finds  in  this 
book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 
work ." — Philadelphia  Medical  Journal. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald, 
of  Munich.  Edited  by  Charles  P.  Grayson,  M.  D.,  Physician-in-Charge, 
Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  25  text-illustrations,  and  103  pages 
of  text.     Cloth,  ^2.50  net. 

"Aided  as  it  is  by  magnificently  executed  illustrations  in  color,  it  cannot  fail  of  being  of 
the  greatest  advantage  to  students,  general  practitioners,  and  expert  laryngologists." — St. 
Louis  Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl, 
of  Vienna.  Edited  by  J.  Chalmers  DaCosta,  M.  D.,  Clinical  Professor 
of  Surgery,  Jefferson  Medical  College,  Philadelphia.  With  24  colored  plates, 
217  text-illustrations,  and  395  pages  of  text.     Cloth,  ^3.00  net. 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of  oper- 
ative surgery." — Mlinchener  medicinische  IVochcnschrift. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.    By 

Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs, 
M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  With  71  colored  plates,  16  black-and- 
white  illustrations,  and  122  pages  of  text.     Cloth,  ^3.50  net. 

"A  glance  through  the  book  is   almost   like  actual  attendance  upon  a  famous   clinic." — 

JourJial  of  the  American  Medical  Association. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye.    By  Dr.  O- 

Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of 
Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  76  colored 
illustrations  on  40  plates,  and  228  pages  of  text.     Cloth,  ^3.00  net. 

"  It  is  always  difficult  to  represent  pathological  appearances  in  colored  plates,  but  this 
work  seems  to  have  overcome  these  difficulties,  and  the  plates,  with  one  or  two  exceptions, 
are  absolutely  satisfactory." — Boston  Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek, 
of  Vienna.  Edited  by  Henry  W.  Stelwagon,  M.  D.,  Clinical  Professor 
of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  With  63  colored 
plates,  39  half-tone  illustrations,  and  200  pages  of  text.    Cloth,  $3.50  net. 

"The  importance  of  personal  inspection  of  cases  in  the  study  of  cutaneous  diseases  is 
readily  appreciated,  and  next  to  the  living  subjects  are  pictures  which  will  show  the  appear- 
ance of  the  disease  under  consideration.  Altogether  the  work  will  be  found  of  very  great 
value  to  the  general  practitioner." — Journal  of  the  Atnerican  Medical  Association. 

4 


SAUNDERS^  MEDICAL  HAND-ATLASES. 


VOLUMES  IN  PRESS  FOR  EARLY  PUBLICATION. 
Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dr.  Ed. 

GOLEBIEWSKI,  of  Berlin.  Translated  and  edited  with  additions  by  Pearce 
Bailey,  M.I).,  Attending  Physician  to  the  Department  of  Corrections 
and  to  the  Almshouse  and  Incurable  Hospitals,  New  York.  With  40 
colored  plates,  143   text-illustrations,  and  600  pages  of  text. 

Atlas  and  Epitome  of  Special  Pathological  Histology.     By  Dr.  H. 

DuRCK,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.D.,  Professor  of 
Pathology,  Rush  Medical  College,  Chicago.  Two  volumes,  with  about 
120  colored  plates,  numerous  text-illustrations,  and  copious  text. 

Atlas  and  Epitome  of  General  Pathological  Histology.  With  an 
Appendix  on  Patho-histological  Technic.  By  Dr.  H.  DiJRCK,  of  Munich. 
Edited  by  LuDViG  Hektoen,  M.D.,  Professor  of  Pathology,  Rush  Medi- 
cal College,  Chicago.  With  So  colored  plates,  numerous  text-illustrations, 
and  copious  text. 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  the 
University  of  Heidelberg.  With  90  colored  plates,  65  text-illustrations, 
and  308  pages  of  text.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D., 
Gynecologist  to  the  Philadelphia  and  the  Methodist  Episcopal  Hospitals. 

IN  PREPARATION. 

Atlas  and  Epitome  of  Orthopedic  Surgery.  By  Dr.  Schultess  and 
Dr.  Tuning,  of  Zurich.     About  100  colored  illustrations. 

Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaffer, 
of  Heidelberg.  With  40  colored  plates  and  numerous  illustrations  in 
black  and  white  from  original   paintings. 

Atlas  and  Epitome  of  Diseases  of  the  Ear.     Edited  by  Prof.  Dr. 

POLITZER,  of  Vienna,  and  Dr.  G.  Bruhl,  of  Berlin.      With  120  colored 

illustrations  and  about  200  pages  of  text. 
Atlas  and  Epitome  of  General  Surgery.     Edited  by  Dr.  Marwedel, 

with  the  cooperation  of  Prof.   Dr.  Czerny.     With  about  200  colored 

illustrations. 
Atlas  and  Epitome  of  Psychiatry.    By  Dr.  Wilh.  Weygandt,  of  Wurz- 

burg.      With  about  120  colored  illustrations. 
Atlas  and  Epitome  of  Normal  Histology.   By  Dr.  Johannes  Sobotta, 

of  Wurzburg.     With  80  colored  plates  and  numerous  illustrations. 
Atlas  and  Epitome  of  Topographical   Anatomy.      By  Prof.   Dr. 

ScHULTZE,  of  Wiirzburg.     About   100  colored   illustrations  and  a   very 

copious  text. 

5 


W.   B.   SAUNDERS' 


*THE    INTERNATIONAL    TEXT-BOOK    OF    SURGERY.     In 

two  volumes.  By  American  and  British  authors.  Edited  by  J.  Col- 
lins Warren,  M.D.,LL.D.,  Professor  of  Surgery,  Harvard  Medical  School, 
Boston ;  Surgeon  to  the  Massachusetts  General  Hospital ;  and  A.  Pearce 
Gould,  M.  S.,  F.  R.  C.  S.,  Eng.,  Lecturer  on  Practical  Surgery  and  Teacher 
of  Operative  Surgery,  Middlesex  Hospital  Medical  School ;  Surgeon  to  the 
Middlesex  Hospital,  London,  England.  Vol.  L — General  and  Operative 
Surgery. — Handsome  octavo  volume  of  947  pages,  with  458  beautiful 
illustrations,  and  9  lithographic  plates.  Vol.  H. — Special  or  Regional 
Surgery. — Handsome  octavo  volume  of  1050  pages,  with  over  500  vi'ood- 
cuts  and  half-tones,  and  8  lithographic  plates.  Prices  per  volume  :  Cloth, 
^5.00  net ;  Half-Morocco,  ^6.00  net. 

Just  Issued, 

In  presenting  a  new  work  on  surgery  to  the  medical  profession  the  publisher 
feels  that  he  need  offer  no  apology  for  making  an  addition  to  the  list  of  excellent 
works  already  in  existence.  Modern  surgery  is  still  in  the  transition  stage  of  its 
development.  The  art  and  science  of  surgery  are  advancing  rapidly,  and  the 
number  of  workers  is  now  so  great  and  so  widely  spread  through  the  whole  of 
the  civilized  world  that  there  is  certainly  room  for  another  work  of  reference 
which  shall  be  untrammelled  by  many  of  the  traditions  of  the  past,  and  shall  at 
the  same  time  present  with  due  discrimination  the  results  of  modern  progress. 
There  is  a  real  need  among  practitioners  and  advanced  students  for  a  work  on 
surgery  encyclopedic  in  scope,  yet  so  condensed  in  style  and  arrangement  that 
the  matter  usually  diffused  through  four  or  five  volumes  shall  be  given  in  one- 
half  the  space  and  at  a  correspondingly  moderate  cost. 

The  ever-widening-field  of  surgery  has  been  developed  largely  by  special 
work,  and  this  method  of  progress  has  made  it  practically  impossible  for  one 
man  to  write  authoi-itatively  on  the  vast  range  of  subjects  embraced  in  a  modern 
text-book  of  surgery.  In  order,  therefore,  to  accomplish  their  object,  the  editors 
have  sought  the  aid  of  men  of  wide  experience  and  established  reputation  in  the 
various  departments  of  surgery. 

COX  TRIBIJTORS : 


Dr.  Robert  W.  Abbe. 
C.  H.  Golding  Bird. 
E.  H.  Bradford. 
W.  T.  Bull. 
T.  G.  A.  Burns. 
Herbert  L.  Burrell. 
R.  C.  Cabot. 
I.  H.  Cameron. 
James  Cantlie. 
W.  Watson  Cheyne. 
William  B.  Clarke. 
William  B.  Coley. 
Edw.  Treacher  Collins. 
H.  Holbrook  Curtis. 
J.  Chalmers  Da  Costa. 
N.  P.  Dandridge. 
John  B.  Deaver. 
J.  W.  Elliot. 
Harold  Ernst. 


Dr.  Christian  Fenger. 
W.  H.  Forwood. 
George  R.  Fowler. 
George  W.  Gay. 
A.  Pearce  Gould. 
J.  Orne  Green. 
John  B.  Hamilton. 
M.  L.  Harris. 
Fernand  Henrotin. 
G.  H.  Makins. 
Rudolph  Matas. 
Charles  McBurney. 
A.  J.  McCosh. 
L.  S.  McMurtry. 
J.  Ewing  Mears. 
George  H.  Monks. 
John  Murray. 
Robert  W.  Parker. 


Dr.  Rushton  Parker. 
George  A.  Peters. 
Franz  Pfaff. 
Lewis  S.  Pilcher. 
James  J.  Putnam. 
M.  H.  Richardson. 
A.  W.  Mayo  Robson. 
W.  L.  Rodman. 
C.  A.  Siegfried. 
G.  B.  Smith. 
W.  G.  Spencer. 
J.  Bland  Sutton. 
L.  McLane  Tiffany. 
H.  Tuholske. 
Weller  Van  Hook. 
James  P.  Warbasse. 
J.  Collins  Warren. 
De  Forest  Willard. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  H.  Howell,  Ph.D.,  M.  D.,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume 
of  1052  pages,  fully  illustrated.  Prices  :  Cloth,  ^6.00  net;  Sheep  or  Half- 
Morocco,  $7.00  net. 

This  work  is  the  most  notable  attempt  yet  made  in  America  to  combine  in 
one  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  write. 
The  completed  work  represents  the  present  status  of  the  science  of  Physiology, 
particularly  from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

The  collaboration  of  several  teachers  in  the  prepaiation  of  an  elementary  text- 
book of  physiology  is  unusual,  the  almost  invariable  rule  heretofore  having  been 
for  a  single  author  to  write  the  entire  book.  One  of  the  advantages  to  be  derived 
from  this  collaboration  method  is  that  the  more  lim.ited  literature  necessary  for 
consultation  by  each  author  has  enabled  him  to  base  his  elementary  account 
upon  a  comprehensive  knowledge  of  the  subject  assigned  to  him ;  another,  and 
perhaps  the  most  important,  advantage  is  that  the  student  gains  the  point  of  view 
of  a  number  of  teachers.  In  a  measure  he  reaps  the  same  benefit  as  would  be 
obtained  by  following  courses  of  instruction  under  different  teachers.  The 
different  standpoints  assumed,  and  the  differences  in  emphasis  laid  upon  the 
various  lines  of  procedure,  chemical,  physical,  and  anatomical,  should  give  the 
student  a  better  insight  into  the  methods  of  the  science  as  it  exists  to-day.  The 
work  will  also  be  found  useful  to  many  medical  practitioners  who  may  wish  to 
keep  in  touch  with  the  development  of  modern  physiology. 

COXTRIBFTORS : 

HENRY  P.  BOWDITCH,  M.  D., 

Professor  of  Physiology,  Harvard  Medi- 
cal School. 


JOHN  G.  CURTIS,  M.  D., 

Professor  of  Physiology,  Columbia  Uni- 
versity, N.  Y.  (College  of  Physicians 
and  Surgeons). 

HENRY  H.  DONALDSON,  Ph.D., 

Head-Professor  of  Neurology,  Univer- 
sity of  Chicago. 

W.  H.  HOWELL,  Ph.  D.,  M.  D., 

Professor  of  Physiology,  Johns  Hopkins 
Universit}'. 

FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Professor  of  Physiology,  Colum- 
bia University,  N.  Y.  (College  of 
Physicians  and  Surgeons). 

"We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  s\xh]itzx.s."  —  London  Lancet. 

"To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the  Eng- 
lish \-aM%\xz.'gs.." —American  Journal  of  the  Medical  Sciences. 


WARREN  P.  LOMBARD,  M.D., 

Professor   of  Physiology,  University  of 
Michigan. 

GRAHAM  LUSK,  Ph.D., 

Professor  of  Physiology,    Yale   Medica' 
School. 

W.  T.  PORTER,  M.D., 

Assistant  Professor  of  Physiology,  Har- 
vard Medical  School. 

EDWARD  T.  REICHERT,  M.D., 

Professor  of  Physiology,  University   of 
Pennsylvania. 

HENRY  SEWALL,  Ph.  D.,  M.  D.. 

Professorof  Physiology,  Medical  Depart- 
ment, University  of  Denver. 


8 


Pr.    B.    SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
TICS. For  the  Use  of  Practitioners  and  Students.  Edited  by 
James  C.  Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices:  Cloth,  ^7.00  net;  Sheep  or 
Half- Morocco,  ;^8.oo  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon 
modern  pathologic  doctrines,  beginning  vi^ith  the  intoxications,  and  following 
with  infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined 
origin,  and  finally  the  disorders  of  the  several  bodily  systems — digestive,  re- 
spiratory, circulatory,  renal,  nervous,  and  cutaneous.  It  was  thought  proper  to 
include  also  a  consideration  of  the  disorders  of  pregnancy. 

The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  standpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  knowledge  to  the  prevention,  the  cure,  and  the  allevia- 
tion of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of 
the  book — Applied  Therapeutics — to  indicate  the  course  of  treatment  to  be 
pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used 
at  one  time  or  another. 

The  list  of  contt'ibutors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of 
the  specialties. 

CONTRIBUTORS : 


Dr.  I.  E.  Atkinson,  Baltimore,  Md. 
Sanger  Brown,  Chicago,  lil. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C.  Dabney,  Charlottesville,  Va. 
John  Chalmers  DaCosta,  Philada,,  Pa. 
I.  N.  Danforth,  Chicago,  111. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia,  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.  Edes,  Jamaica  Plain,  Mass. 
Augustus  A.  Eshner,  Philadelphia,  Pa. 
J.  T.  Eskridge,  Denver,  Ccl. 
F.  Forchheimer,  Cincinnafi,  O. 
Carl  Frese,  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras,  Philadelphia,  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  Pa. 
Orville  Horwitz,  Philadelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Pans,  France. 

"As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician."  —  Chicago  Clinical  Revieiv. 

"The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  practical, 
and  while  it  is  intended  for  practitioners  and  students,  it  is  abetter  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful," — The  Indian  Lancet. 


Dr.  James  Hendrie  Lloyd,  Philadelphia,  Pa. 
John  Noland  Mackenzie,  Baltimore,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell,  Philadelphia,  Pa. 
W.  P.  Northrup.  New  York  City. 
William  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Philadelphia,  Pa. 
Theophilus  Parvin,  Philadelphia,  Pa. 
Beaven  Rake,  London,  England. 
E.  O.  Shakespeare,  Philadelphia,  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Philadelphia,  Pa. 
James  Stewart.  Montreal,  Canada. 
Charles  G.  Stockton,  Buffalo,  N.  Y. 
James  I'yson,  Philadelphia,  Pa. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
James  T.  Whittaker,  Cincinnati,  O. 
J.  C.  Wilson,  Philadelphia,  Pa. 


CATALOGUE    OF  MEDICAL    WORKS.  9 

*AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by 
Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L,  Dickinson,  M.  D. 
One  handsome  octavo  volume  of  over  looo  pages,  vv^ith  nearly  900  colored 
and  half-tone  illustrations.  Prices:  Cloth,  $7.00  net;  Sheep  or  Half 
Morocco,  ^8.00  net. 

The  advent  of  each  successive  volume  of  the  series  of  the  American  Text- 
Books  has  been  signalized  by  the  most  flattering  comment  from  both  the  Press 
and  the  Profession.  The  high  consideration  received  by  these  text-books,  and 
their  attainment  to  an  authoritative  position  in  current  medical  literature,  have 
been  mattei-s  of  deep  i)iternational  interest,  which  finds  its  fullest  expression  in 
the  demand  for  these  publications  from  ail  parts  of  the  civilized  world. 

In  the  preparation  of  the  "  xVmerican  Text-Book  of  Obstetrics"  the 
editor  has  called  to  his  aid  proficient  collaborators  whose  professional  prominence 
entitles  them  to  recognition,  and  whose  disquisitions  exemplify  Practical 
Obstetrics.  While  these  writers  were  each  assigned  special  themes  for  dis- 
cussion, the  correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures 
logical  connection  in  treatment,  the  deductions  of  which  thoroughly  represent 
the  latest  advances  in  the  science,  and  which  elucidate  the  best  modern  methods 
of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative 
matter.  The  production  of  the  illustrations  had  been  in  progress  for  several 
years,  under  the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose 
artistic  judgment  and  professional  experience  is  due  the  most  sumptuously 
illustrated  v^rork  of  the  period.  By  means  of  the  photographic  art,  combined 
with  the  skill  of  the  artist  and  draughtsman,  conventional  illustration  is  super- 
seded by  rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the   unsparing  hand  of  its  publisher. 


COXTRIBUTORS  : 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickinson. 
Charles  Warrington  Earle. 
James  H.  Etheridge. 
Henry  J.  Garricues. 
Barton  Cooke  Hirst. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncej'  D.  Palmer. 
Theophilus  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects, 
viz.  :  First,  by  the  size  of  the  volume,  then  by  the  array  of  eminent  teachers  in  this  depart- 
ment who  have  taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the 
illustrations,  and  last,  but  not  least,  the  conciseness  and  clearness  with  which  the  te.xt  is  ren- 
dered. This  is  an  entirely  new  composition,  embodying  the  highest  knowledge  of  the  art  as 
it  stands  to-day  by  authors  who  occupy  the  front  rank  in  their  specialty,  and  there  are  many 
of  them.  We  cannot  turn  over  these  pages  without  being  struck  by  the  superb  illustrations 
which  adorn  so  manj^  of  them.  We  are  confident  that  this  most  practical  work  will  find 
instant  appreciation  by  practitioners  as  well  as  students." — Neiv  York  Medical  Ti7nes. 

Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  1  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours,  Alex.  J.  C.  Skene. 


lO  m   B.   SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal-octavo  volumes  of  about 
looo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume  :  Cloth,  ;^5.oo  net;  Sheep  or  Half-Morocco,  ^6.00  net. 

VOIiUME  I.  CONTAINS: 


Hygiene. — Fevers  (Ephemeral,  Simple  Con- 
tinued, Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Meningitis,  and  Relapsing). — Scarla- 
tina, Measles,  Rotheln,  Variola,  Varioloid, 
Vaccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis, Glanders,  and  Tetanus. — Tubercu- 
losis, Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOI.IJME   II.  CONTAINS: 


Urine  (Chemistry  and  Microscopy). — Kid- 
ney and  Lungs. — Air-passages  (Larynx  and 
Bronchi)  and  Pleura. — Pharynx,  (Esophagus, 
Stomach  and  Intestines  (including  Intestinal 
Parasites),  Heart,  Aorta,  Arteries  and  Veins. 


—  Peritoneum,  Liver, and  Pancreas. — Diathet- 
ic Diseases  (Rheumatism,  Rheumatoid  Ar- 
thritis, Gout,  Lithaemia,  and  Diabetes.) — 
Blood  and  Spleen.— Inflammation,  Embolism, 
Thrombosis,  Fever,  and  Bacteriology. 


The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 

CONTRIBUTORS  ; 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 
W.  Gilman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said:  *  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — Ne7u  York  Medical  jfouj-nal, 

"  A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  diflusion  of 
sound  knowledge." — American  Lancet. 

"A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely." — Edinburgh  Medical  Journal. 


CATALOGUE    OF  MEDICAL    WORKS.  II 

*AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  Wil- 
liam \V.  Keen,  M.  D.,  LL.D.,  and  JAVilliam  Whitk,  M.  D.,  Ph.D. 
Forming  one  handsome  royal  octavo  volume  of  1230  pages  (10x7  inches), 
with  496  wood-cuts  in  text,  and  37  colored  and  half-tone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.     Price  :  Cloth,  $7.00  net:   Sheep  or  Half  Morocco.  $8.00  net. 

THIRD  EDITION.  THOROUGHLY  REVISED. 

in  the  present  edition,  among  the  new  topics  introduced  are  a  full  considera- 
tion of  serum-therapy;  leucocytosis  ;  post-operative  insanity;  the  use  of  dry  heat 
at  high  temperatures ;  Kronlein's  method  of  locating  the  cerebral  fissures ; 
Hoffa's  and  I.orenz's  operations  of  congenital  dislocations  of  the  hip;  Allis's  re- 
searches on  dislocations  of  the  hip-joint ;  lumbar  puncture  ;  the  forcible  reposi- 
tion of  the  spine  in  Pott's  disease;  the  treatment  of  exophthalmic  goiter;  the 
surgery  of  typhoid  fever ;  gastrectomy  and  other  operations  on  the  stomach ; 
new  methods  of  operating  upon  the  intestines;  the  use  of  Kelly's  rectal  specula; 
the  surgery  of  the  ureter ;  Schleich's  infiltration-method  and  the  use  of  eucain 
for  local  anesthesia ;  Krause"s  method  of  skin-grafiing  ;  the  newer  methods  of 
disinfecting  the  hands ;  the  use  of  gloves,  etc.  The  sections  on  Appendicitis, 
on  Fractures,  and  on  Gynecological  Operations  have  been  revised  and  enlarged. 
A  considerable  number  of  new  illustrations  have  been  added,  and  enhance  the 
value  of  the  work. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book-making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  original  and  faithful  reproductions  of  p'notographs  taken 
directly  from  patients  or  from  specimens, 

eONTRIBUTOBS  % 


Dr.  Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charles  B.  Nancrede,  Ann  Arbor,  ]Mich. 
Roswell  Park.  Buffalo,  New  York. 
Lewis  S.  Pilcher.  New  York. 


■Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd,  Montreal,  Canada, 

Lewis  A.  Siimson,  New  York. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgerj',  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  wiil  have  to  look  very 
careiuilv  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
Lotidon  Lancet. 

Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text-Book), 
for  1  know  ot  no  single  volume  which  contains  so  readable  and  complete  an  account  of  the 
science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F.  R.  C.  S.,  Member  of  the  Boa7-d 
((f  ExaDiiners  of  the  Royal  College  of  Surgeons ,  Lnz-ana. 


12  fV.   B.   SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students   and   Practitioners. 

Edited  by  J.  M.  Baldy,  M.  D.  Forming  a  handsome  royal-octavo  volume 
of  718  pages,  with  341  illustrations  in  the  text  and  38  colored  and  half- 
tone plates.     Prices  :  Cloth,  ^6.00  net;  Sheep  or  Half-Morocco,  $7.00  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students,  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

In  the  revised  edition  much  new  material  has  been  added,  and  some  of  the 
old  eliminated  or  modified.  More  than  forty  of  the  old  illustrations  have  been 
replaced  by  new  ones,  which  add  very  materially  to  the  elucidation  of  the 
text,  as  they  picture  methods,  not  specimens.  The  chapters  on  technique  and 
after-treatment  have  been  considerably  enlarged,  and  the  portions  devoted  to 
plastic  work  have  been  so  greatly  improved  as  to  be  practically  new.  Hyste- 
rectomy has  been  rewritten,  and  all  the  descriptions  of  operative  procedures 
have  been  carefully  revised'  and  fully  illustrated. 


CONTRIBVTORIS  ; 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
](.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887 and  the  most 

complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  aftd  Surgical 
journal. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempereu  advice  and  In- 
struction."— Edinburgh  Medical  Journal, 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annals  of  Smgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  of  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


13 


*AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  Thompson  S.  Westcott,  M.  D.  In  one  handsome  royal-8vo 
volume  of  1244  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices:  Cloth,  $7.00;   Sheep  or  Half-Morocco,  38.00. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  pc^diatrists,  representing  collectively  the  teachmgs  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

In  this  new  edition  the  whole  subject  matter  has  been  carefully  revised,  new 
articles  added,  some  original  papers  emended,  and  a  number  entirely  rewritten. 
The  new  articles  include  "  Modified  Milk  and  Percentage  Milk-Mixtures," 
"  Lithemia,"  and  a  section  on  "  Orthopedics."  Those  rewritten  are  "  Typhoid 
Fever,"  "Rubella,"  "Chicken-pox,"  "Tuberculous  Meningitis,"  "Hydroceph- 
alus," and  "Scurvy;"  while  extensive  revision  has  been  made  in  "Infant 
Feeding,"  "  Measles,"  "  Diphtheria,"  and  "  Cretinism."  The  volume  has  thus 
been  much  increased  in  size  by  the  introduction  of  fresh  material. 


Dr. 


COXTKIBUTORS 1 


S.  S.  Adams,  Washington. 
John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
David  Bovaird,  New  York. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York.. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCosta,  Philadelphia. 
T.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
J.  P.  Crozer  Griihth,  Philadelphia. 
W.  A.  Hardawav.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik,  New  York. 


Dr.  Tliomas  S.  Latimer.  Baltimore. 

Albert  R.  Leeds,  Hoboken,  N.  J. 

J.  Hendrie  Lloyd,  Philadelphia. 

George  Roe  Lockwood,  New  York. 

Henry  M.  Lyman,  Chicago. 

Francis  T.  Miles,  Baltimore. 

Charles  K    Mills,  Philadelphia. 

James  E    Moore,  Minneapolis. 

F.  Gordon  Morrill,  Boston. 

John  H.  Musser,  Philadelphia. 

Thomas  R.  Neilson,  Philadelphia. 

W.  P.  Northrup,  New  York. 

William  Osier,  Baltimore. 

Frederick  A.  Packard,  Philadelphia. 

William  Pepper,  Philadelphia. 

Frederick  Peterson,  New  York. 

W.  T.  Plant,  Syracuse,  New  York. 

William  M.  Powell.  Atlantic  City. 

B.  K.  Rachford,  Cincinnati. 

B.  Alexander  Randall,  Philadelphia. 

Edward  O.  Shakespeare,  Philadtlphia 

F.  C.  Shattuck,  Boston. 

J.  Lewis  Smith,  New  York. 

Louis  Starr,  Philadelphia. 

M.  Allen  .Starr,  New  York. 

Charles  W.  Townsend,  Boston. 

James  Tyson,  Philadelphia. 

W.  S.  Thayer,  Baltimore. 

Victor  C.  Vaughan,  Ann  Arbor,  Mich 

Thompson  S.  Westcoit,  Philadelphia. 

Henry  R.  Wharton,  Philadelphia. 

J.  William  White,  Philadelphia. 

J.  C.  Wilson,  Philadelphia. 


14 


IV.   B.    SAUNDERS' 


*  AN  AMERICAN  TEXT-BOOK  OF  GENITO-URINARY  AND 
SKIN  DISEASES.  By  47  Eminent  Specialists  and  Teachers.  Edited 
by  L.  Bolton  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  Uni- 
versity and  Bellevue  Hospital  Medical  College,  New  York;  and  W.  A. 
Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical 
College.  Imperial  octavo  volume  of  1229  pages,  with  300  engravings  ana 
20  full-page  colored  plates.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
^8.00  net. 

This  addition  to  the  series  of  "  American  Text-Books,"  it  is  confidently  be- 
lieved, will  meet  the  requirements  of  both  students  and  practitioners,  giving,  as 
it  does,  a  comprehensive  and  detailed  presentation  of  the  Diseases  of  the 
Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the  Affections  of  the 
Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches 
represented  in  the  undertaking,  the  editors  have  not  restricted  the  contributors 
iu  regard  to  the  particular  views  set  forth,  but  have  offered  every  facility  for  the 
free  expression  of  their  individual  opinions.  The  work  will  therefore  be  found 
to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concernea. 


CONTRIBUTORS ! 


Dr.  Chas.  W.  Allen,  New  York. 
I.  E.  Atkinson,  Baltimore. 
L    Bolton  Bangs,  New  York. 
P.  R.  Bolton,  New  York. 
Lewis  C.  Bosher,  Richmond,  Va. 
John  T,  Bowen,  Boston. 
J.  Abbott  Cantrell,  Philadelphia. 
William  T.  Corlett,  Cleveland,  Ohio. 
B.  Farquhar  Curtis,  New  York. 
Condict  W.  Cutler,  New  York. 
Isadore  Dyer,  New  Orleans. 
Christian  Fenger,  Chicago. 
John  A.  Fordyce,  New  York. 
Eugene  Fuller,  New  York. 
R.  H.  Greene,  New  York. 
Joseph  Grindon,  St.  Louis. 
Graeme  M.  Hammond,  New  York. 
W.  A.  Hardaway,  St.  Louis. 
M.  B.  Hartzell,  Philadelphia. 
Louis  Heitzmann,  New  York. 
James  S.  Howe,  Boston. 
George  T.  Jackson,  New  York. 
Abraham  Jacobi,  New  York. 
James  C.  Johnston.  New  YOik. 


Dr.  Hermann  G.  Kiotz,  New  YorK. 
J.  H.  Linsley,  Burlington,  Vt. 
G.  F.  Lydston,  Chicago. 
Hartwell  N.  Lyon,  St.  Louis. 
Edward  Martin,  Philadelphia. 
D.  G.  Montgomery,  San  Francisco. 
James  Pedersen,  New  York. 
S.  Pollitzer,  New  York. 
Thomas  R.  Pooley,  New  York. 
A.  R.  Robinson,  New  York. 
A.  E.  Regensburger,  San  Francisco. 
Francis  J.  Shepherd,  Montreal,  Can. 
S.  C.  Stanton,  Chicago,  111. 
Emmanuel  J.  Stout,  Philadelphia. 
Alonzo  E.  Taylor    Philadelphia. 
Robert  W.  Taylor,  New  York. 
Paul  Thorndike,  Boston. 
H.  Tuholske,  St.  Louis. 
Arthur  Van  Harlingen,  Philadelphia. 
Francis  S.  Watson,  Boston. 
J.  William  White,  Philadelphia. 
J.  McF.  Winfield,  Brooklyn. 
Alfred  C.  Wood.  PhiladelDma. 


"This  voluminous  work  is  thoroughly  up  to  date,  and  the  chapters  on  genito-urinar^'  ais- 
eases  are  especially  valuable.  The  ilhistrations  are  fine  and  are  mostly  original.  1'he  section 
on  dermatology  is  concise  and  in  every  way  admirable."— .A?;c;-;/a/  of  the  American  Medical 
Association. 

"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of  'American  Text- 
Books.'  The  list  of  contributors  represents  an  extraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiv.eness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  hitherto  been  necessary  to  a 
well-equipped  library." — New  York  Folvclinic, 


CATALOGUE    OF  MEDICAL    WORKS. 


15 


*  AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE, 
EAR,  NOSE,  AND  THROAT.    Ediiedby  Gkok(;eE.  di:  Schweinitz, 

A.  M.,  M.  1).,  Professor  of  Ophthalmology,  Jefferson  Medical  College;  and 

B.  Alexander  Randall,  A.  M.,  M.  D.,  Clinical  Professor  of  Diseases  of 
the  Ear,  University  of  Pennsylvania.  One  handsome  imperial  octavo 
volume  of  1251  pages;  766  illustrations,  59  of  them  colored.  Prices: 
Cloth,  ^7.00  net;  Sheep  or  Half-Morocco,  ^8.00  net. 

Just  Issued, 

The  present  work  is  the  only  book  ever  published  embracing  diseases  of  the 
intimately  related  organs  of  the  eye,  ear,  nose,  and  throat.  Its  special  claim 
to  favor  is  based  on  encyclopedic,  authoritative,  and  practical  treatment  of  the 
subjects. 

Each  section  of  the  book  has  been  entrusted  to  an  author  who  is  specially 
identified  with  the  subject  on  which  he  writes,  and  who  therefore  presents  his 
case  in  the  manner  of  an  expert.  Uniformity  is  secured  and  overlapping  pre- 
vented by  careful  editing  and  by  a  system  of  cross-references  which  forms  a 
special  feature  of  the  volume,  eivibling  the  reader  to  come  into  touch  with  all 
that  is  said  on  any  subject  in  different  portions  of  the  book. 

Particular  emphasis  is  laid  on  the  most  approved  methods  of  treatment,  so 
that  the  book  shall  be  one  to  which  the  student  and  practitioner  can  refer  for 
information  in  practical  work.  Anatomical  and  physiological  problems,  also, 
are  fully  discussed  for  the  benefit  of  those  who  desire  to  investigate  the  more 
abstruse  problems  of  the  subject. 


CONTRIBUTORS ; 


Dr.  Henry  A.  Alderton,  Brooklyn. 
Harrison  Allen,  Philadelphia. 
Frank  Allpor:,  Chicago. 
Morris  J.  Asch.  New  York. 
S.  C.  Ayres,  Cincinnati. 
R.  O.  Beard,  Minneapoh's. 
Clarence  J.  Blake,  Boston. 
Arthur  A.  Bliss,  Philadelphia. 
Albert  P.  Brubaker,  Philadelphia. 
J.  H.  Bryan,  Washington,  D.  C. 
Albert  H.  Buck,  New  York. 
F.  BuUer,  Montreal,  Can. 
Swan  M.  Burnett,  Washington,  D    C. 
Flemming  Carrow,  Ann  Arbor,  Mich. 
W.  E.  Casselberry,  Chicago. 
Colman  W.  Cutler,  New  York. 
Edward  B.  Dench,  New  York. 
William  S.  Dennett,  New  York. 
George  E.  de  Schweinitz,  Philadelphia. 
Alexander  Duane,  New  York. 
John  W.  Farlow,  Boston,  Mass. 
Walter  J.  Freeman,  Philadelphia. 
H.  Gifford,  Omaha,  Neb. 
W.  C.  Glasgow,  St.  Louis. 
J    Orne  Green,  Boston. 
Ward  A.  Holden,  New  York. 
Christian  R.  Holmes,  Cincinnati. 
William  E.  Hopkins,  San  Francisco. 
F.  C.  Hotz,  Chicago. 
Lucien  Howe,  Buffalo,  N.  Y. 


Dr.  Alvin  A.  Hubbell,  Buffalo,  N.  Y. 
Edward  Jackson,  Philadelphia. 
J.  Ellis  Jennings,  St.  Louis. 
Herman  Knapp,  New  York. 
Chas.  W.  Kollock,  Charleston,  S.  C. 
G.  A.  Leland,  Boston. 
J.  A.  Lippincott,  Pittsburg,  Pa. 
G.  Hudson  Makuen,  Philadelphia. 
John  H.  McCollom,  Boston. 
H.  G.  Miller,  Providence.  R.  L 
B.  L.  MiUiken,  Cleveland,  Ohio. 
Robert  C.  Myles,  New  York. 
James  E.  Newcomb,  New  York. 
R.  J.  Phillips,  Philadelphia. 
George  A.  Piersol,  Philadelphia. 
W.  P.  Porcher,  Charleston,  S.  C. 
B.  Alex.  Randall,  Philadelphia. 
Robert  L.  Randolph,  Baltimore. 
John  O.  Roe,  Rochester,  N.  Y. 
Charles  E.  de  M.  Sajous,  Philadelphia. 
J.  E.  Sheppard,  Brooklyn,  N.  Y. 
E.  L.  Shurly,  Detroit,  Mich. 
William  M.  Sweet,  Philadelphia. 
Samuel  Theobald.  Baltimore,  Md. 
A.  G.  Thomson,  Philadelphia. 
Clarence  A.  Veasey,  Philadelphia. 
John  E.  Weeks,  New  York. 
Casey  A.  Wood,  Chicago,  111. 
Jonathan  Wright,  Brooklyn. 
H.  V.  Wiirdemanii,  Milwaukee,  Wis. 


i6 


IV.    B.   SAUNDERS' 


*AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SUR- 
GERY. A  Yearly  Digest  of  Scientific  Progress  and  Authoiritative 
Opinion  in  all  branches  of  Medicine  and  Surgery,  drawn  from  journals* 
monographs,  and  text-books  of  the  leading  American  and  Foreign  authors 
and  investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.  D.  Volumes  for  1896,  '97, 
'98,  and  '99  each  a  handsome  imperial  octavo  volume  of  about  1200  pages. 
Prices  :  Cloth,  ^6.50  net ;  Half-Morocco,  ^7.50  net.  Year-Book  for  1900  in 
two  octavo  volumes  of  about  600  pages  each.  Prices  per  volume :  Cloth, 
^3.00  net;  Half-Morocco,  ^3.75  net. 


In  Two  Volttmes*    No  Increase  in  Price* 

In  response  to  a  widespread  demand  from  the  medical  profession,  the  pub- 
lisher of  the  "American  Year-Book  of  Medicine  and  Surgery"  has  decided  to 
issue  that  well-known  work  in  two  volumes,  Vol.  I.  treating  of  General  Medi- 
cine, Vol.  11.  of  General  Surgery.  Each  volume  is  complete  in  itself,  and 
the  work  is  sold  either  separately  or  in  sets. 

This  division  is  made  in  such  a  way  as  to  appeal  to  physicians  from  a  class 
standpoint,  one  volume  being  distinctly  medical,  and  the  other  distinctly  surgi- 
cal. This  arrangement  has  a  two-fold  advantage.  To  the  physician  who  uses 
the  entire  book,  it  offers  an  increased  amount  of  matter  in  the  most  convenient 
form  for  easy  consultation,  and  without  any  increase  in  price;  while  the  man 
who  wants  either  the  medical  or  the  surgical  section  alone  secures  the  comjilete 
consideration  of  his  branch  without  the  necessity  of  purchasing  matter  for  which 
he  has  no  use. 

CONTRIBUTORS : 


Vol.  I. 
Dr.  Samuel  W.  Abbott.  Boston. 
Archibald  Church,  Chicago. 
Louis  A.  Duhring,  Philadelphia. 
D.  L.  Edsall,  Philadelphia. 
Alfred  Hand,  Jr.,  Philadelphia. 
M.  B.  Hartzell,  Philadelphia. 
Reid  Hunt,  Baltimore. 
Wyatt  Johnston,  Montreal. 
Walter  Jones,  Baltimore. 
David  Kiesman,  Philadelphia. 
Louis  Starr,  Philadelphia.  _ 
Alfred  Stengel,  Philadelphia. 
A.  A.  Stevens,  Philadelphia. 
G.  N.  Stewart.  Cleveland. 
Reynold  W.  Wilcox,  New  York  City. 


Vol.  IL 
Dr.  J.  Montgomery  Baldy,  Philadelphia. 
Charles  H.  Burnett,  Philadelphia. 
J.  Chalmers  DaCosta,  Philadelphia. 
W.  A.    N.  Dorland,  Philadelphia. 
Virgil  P.  Gibney,  New  York  City. 
C.  H.  Hamann,  Cleveland. 
Howard  F.  Hansell,  Philadelphia. 
Barton  Cooke  Hirst,  Philadelphia. 
E.  Fletcher  Ingals,  Chicago. 
W.  W.  Keen,  Philadelphia. 
Henry  G.  Ohls,  Chicago. 
Wendell  Reber,  Philadelphia. 
J.  Hilton  Waterman,  New  York  City. 


"It  is  difficult  to  know  which  to  admire  most— the  research  and  industry  of  the  distm- 
guished  band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Year-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advan- 
tage of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous  '  Jahrbucher ' 
of  Germany." — London  Lancet. 


CATALOGUE    OF  MEDICAL    WORKS.  ly 

*  ANOMALIES  AND  CURIOSITIES  OF  MEDICINE.  By  George 
M.  GuULD,  M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collec- 
tion of  are  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an  ex- 
haustive research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  imperial  octavo 
volume  of  968  pages,  with  295  engravings  in  the  text,  and  12  full-page 
plates.     Cloth,  $3.00  net ;   Half-Morocco,  $4.00  net. 

POPULAR  EDITION  REDUCED  FROM  $6,00  to  $3.00, 

In  view  of  the  great  success  of  this  magnificent  work,  the  publisher  has  decided 
to  issue  a  "  Popular  Edition  "  at  a  price  so  low  that  it  may  be  procured  by  every 
student  and  practitioner  of  medicine.  Notwithstanding  the  great  reduction  in 
price,  there  will  be  no  depreciadon  in  the  excellence  of  typography,  paper,  and 
binding  that  characterized  the  earlier  editions. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors  in  the 
great  medical  libraries  of  the  United  States  and  Europe  in  collecting  the  mate- 
rial for  this  work.  Medical  literature  of  all  ages  and  all  languages  has 
been  carefully  searched,  as  a  glance  at  the  Bibliographic  Index  will  show.  The 
facts,  which  will  be  of  extreme  value  to  the  author  and  lecturer,  have  been 
arranged  and  annotated,  and  full  reference  footnotes  given. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far  as 
we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for  the 
medical  profession  has  this  volume  value  :  it  will  serve  as  a  book  of  reference  for  all  who  are 
interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical  jour- 
nal. 

NERVOUS  AND  MENTAL  DISEASES.  By  Archibald  Church, 
M.  D.,  Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical 
Jurisprudence,  Northwe.stern  University  Medical  School ;  and  Frederick 
Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medi- 
cal College,  New  York.  Handsome  octavo  volume  of  843  pages,  with 
over  300  illustrations.     Prices:    Cloth,  $5.00  net;    Half- Morocco,  S6.00 

net. 

Second  Edition, 

This  book  is  intended  to  furnish  students  and  practitioners  with  a  practical, 
working  knowledge  of  nervous  and  mental  diseases.  Written  by  men  of  wide 
experience  and  authority,  it  presents  the  many  recent  additions  to  the  subject. 
The  book  is  not  filled  with  an  extended  dissertation  on  anatomy  and  pathology, 
but,  treating  these  points  in  connection  with  special  conditions,  it  lays  particular 
stress  on  methods  of  examination,  diagnosis,  and  treatment.  In  this  respect  the 
work  is  unusually  complete  and  valuable,  laying  down  the  definite  courses  of 
procedure  which  the  authors  have  found  to  be  most  generally  satisfactory.    . 

"  The  work  is  an  epitome  of  what  is  to-day  known  of  nervous  diseases  prepared  for  the 
student  and  practitioner  in  the  light  of  the  author's  experience  .  .  .  We  believe  that  no  v/ork 
presents  the  difficult  subject  of  insanity  in  such  a  reasonable  and  readable  way." — Chicago 
Medical  Recorder. 


1 8  ^V.   B.   SAUNDERS' 


DISEASES  OF  THE  NOSE  AND  THROAT.     By  D.  Braden  Kyle, 

M.  D.,  Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medi- 
cal College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Olologist,  St.  Agnes'  Hospital.  Octavo  volume  of  646  pages,  with  over 
150  illustrations  and  6  lithographic  plates.  Cloth,  ^4.00  net;  Half-Mo- 
rocco, ^5.00  net. 

Just  Issued, 

This  book  presents  the  subject  of  Diseases  of  the  Nose  and  Throat  in  as  con- 
cise a  manner  as  is  consistent  with  clearness,  keeping  in  mind  the  needs  of  the 
student  and  general  practitioner  as  well  as  those  of  the  specialist.  The  arrange- 
ment and  classification  are  based  on  modern  pathology,  and  the  pathological 
views  advanced  are  supported  by  drawings  of  microscopical  sections  made  in  the 
author's  own  laboratory.  These  and  the  other  illustrations  are  particularly  fine, 
being  chiefly  original.  With  the  practical  purpose  of  the  book  in  mind,  ex- 
tended  consideration  has  been  given  to  details  of  treatment,  each  disease  being 
considered  in  full,  and  -definite  courses  being  laid  down  to  meet  special  condi- 
tions and  symptoms. 

"  It  is  a  thorough,  full,  and  systematic  treatise,  so  classified  and  arranged  as  greatly  to  facili- 
tate the  teaching  of  laryngology  and  rhinology  to  classes,  and  must  prove  most  convenient 
and  satisfactory  as  a  reference  book,  both  for  students  and  practitioners." — International 
Medical  Magazine. 

THE  HYGIENE  OF  TRANSMISSIBLE  DISEASES  :  their  Causa- 
tion, Modes  of  Dissemination,  and  Methods  of  Prevention.  By 
A.  C.  Abbott,  M.  D.,  Professor  of  Hygiene  in  the  University  of  Pennsyl- 
vania; Director  of  the  Laboratory  of  Hygiene.  Octavo  volume  of  3II 
pages,  with  charts  and  maps,  and  numerous  illustrations.     Cloth,  $2.00  net. 


Just  Issued. 

It  is  not  the  purpose  of  this  work  to  present  the  subject  of  Hygiene  in  the 
comprehensive  sense  ordinarily  implied  by  the  word,  but  rather  to  deal  directly 
with  but  a  section,  certainly  not  the  least  important,  of  the  subject — viz.,  that 
embracing  a  knowledge  of  the  preventable  specific  diseases.  The  book  aims  to 
furnish  information  concerning  the  detailed  management  of  transmissible  dis- 
eases. Incidentally  there  are  discussed  those  numerous  and  varied  factors  that 
have  not  only  a  direct  bearing  upon  the  incidence  and  suppression  of  such  dis- 
eases, but  are  of  general  sanitary  importance  as  well. 

"  The  vi'ork  is  admirable  in  conception  and  no  less  so  in  execution.  It  is  a  practical  work, 
simply  and  lucidly  written,  and  it  should  prove  a  most  helpful  aid  in  that  department  of 
medicine  which  is  becoming  daily  of  increasing  importance  and  application — namely,  prophj'- 
laxis." — Philadelphia  Medical  Jou7-nal. 

"  It  is  scientific,  but  not  too  technical ;  it  is  as  complete  as  our  present-day  knowledge  of 
hygiene  and  sanitation  allows,  and  it  is  in  harmony  with  the  efforts  of  the  profession,  which 
are  tending  more  and  more  to  methods  of  prophylaxis.  For  the  student  and  for  the  practi- 
tioner it  is  well  nigh  indispensable." — Medical  News,  New  York. 


CATALOGUE    OF  MEDICAL    WORKS.  ig 

A  TEXT-BOOK  OF  EMBRYOLOGY.  By  John  C.  Heisler,  M.  D.^ 
Professor  of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia, 
Octavo  volume  of  405  pages,  with  190  illustrations,  26  in  colors.  Clotli 
^2.50  net. 

Just  Issued, 

The  facts  of  embryology  having  acquired  in  recent  years  such  great  interest 
in  connection  with  the  teaching  and  with  the  proper  comprehension  of  human 
anatomy,  it  is  of  first  importance  to  the  student  of  medicine  that  a  concise  and 
yet  sufficiently  full  text-book  upon  the  subject  be  available.  It  was  with  the 
aim  of  presenting  such  a  book  that  this  volume  was  written,  the  author,  in  his 
experience  as  a  teacher  of  anatomy,  having  been  impressed  with  the  fact  that 
students  were  seriously  handicapped  in  their  study  of  the  subject  of  embryology 
by  the  lack  of  a  text-book  full  enough  to  be  intelligible,  and  yet  without  that 
minuteness  of  detail  which  characterizes  the  larger  treatises,  and  which  so  often 
serves  only  to  confuse  and  discourage  the  beginner. 

"  In.  short,  the  book  is  written  to  fill  a  want  which  has  distinctly  existed  and  which  it 
definitely  meets  ;  commendation  greater  than  this  it  is  not  possible  to  give  to  anything." — 
Medical  News,  New  York. 

A  MANUAL  OF  DISEASES  OF  THE  EYE.  By  Edward  Jack- 
son, A.  M.,  M.  D.,  sometime  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine.  i2mo,  604 
pages,  with  178  illustrations  from  drawings  by  the  author.    Cloth,  ^2.50  net. 

fJiist  Issued* 

This  book  is  intended  to  meet  the  needs  of  the  general  practitioner  of  medi- 
cine and  the  beginner  in  ophthalmology.  More  attention  is  given  to  the  condi- 
tions that  must  be  met  and  dealt  with  early  in  ophthalmic  practice  than  to  the 
rarer  diseases  and  more  difficult  operations  that  may  come  later. 

It  is  designed  to  furnish  efficient  aid  in  the  actual  work  of  dealing  with  dis- 
ease, and  therefore  gives  the  place  of  first  importance  to  the  recognition  and 
management  of  the  conditions  that  present  themselves  in  actual  clinical  work. 

LECTURES  ON  THE  PRINCIPLES  OF  SURGERY.  By  Charles 
B.  Nancrede,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Handsome  octavo,  398  pages,  illus- 
trated.    Cloth,  ^2.50  net. 

Just  Issued. 

The  present  book  is  based  on  the  lectures  delivered  by  Dr.  Nancrede  to  his 
undergraduate  classes,  and  is  intended  as  a  text-book  for  students  and  a  practi- 
cal help  for  teachers.  By  the  careful  elimination  of  unnecessary  details  of 
pathology,  bacteriology,  etc.,  which  are  amply  provided  for  in  other  courses  of 
study,  space  is  gained  for  a  more  extended  consideration  of  the  Principles  of 
Surgery  in  themselves,  and  of  the  application  of  these  principles  to  methods 
of  practice. 


20  f^.   B.   SAUNDERS' 


A  TEXT-BOOK  OF  PATHOLOGY.  By  Alfred  Stengel,  M.  D., 
Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania ;  Physi- 
cian to  the  Philadelphia  Hospital;  Physician  to  the  Children's  Hospital, 
Philadelphia,  Handsome  octavo  volume  of  848  pages,  with  362  illustra- 
tions, many  of  which  are  in  colors.  Prices:  Cloth,  ^4.00  net;  Half- 
Morocco,  ^5.00  net. 

Second  Edition, 

In  this  work  the  practical  application  of  pathological  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of 
the  book,  an  effort  has  been  made  to  present  the  subject  from  the  point  of  view 
of  the  clinician.  The  general  relations  of  bacteriology  to  pathology  are  dis- 
cussed at  considerable  length,  as  the  importance  of  these  branches  deserves.  It 
will  be  found  that  the  recent  knowledge  is  fully  considered,  as  well  as  older  and 
more  widely-known  facts. 

"  I  consider  the  work  abreast  of  modern  pathology,  and  useful  to  both  students  and  prac- 
titioners. It  presents  in  a  concise  and  well-considered  form  the  essential  facts  of  general  and 
special  pathological  anatomy,  with  more  than  usual  emphasis  upon  pathological  physiology." 
— William  H.  Welch,  Professor  of  Pathology ,  Johns  Hopkins  University ,  Baltimore,  Md. 

"I  regard  it  as  the  most  serviceable  text-book  for  students  on  this  subject  yet  written  by 
an  American  author."  — L.  Hektoen,  Professor  of  Pathology,  Rush  Medical  College, 
Chicago,  III. 

A  TEXT-BOOK  OF  OBSTETRICS.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome  oc- 
tavo volume  of  846  pages,  with  618  illustrations  and  seven  colored  plates. 
Prices :  Cloth,  ^5.00  net ;  Half-Morocco,  ^6.00  net. 

Second  Edition, 

This  work,  which  has  been  in  course  of  preparation  for  several  years,  is  in- 
tended as  an  ideal  text-book  for  the  student  no  less  than  an  advanced  treatise 
for  the  obstetrician  and  for  general  practitioners.  It  represents  the  very  latest 
teaching  in  the  practice  of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes  especially,  as  a  work  on  obstetrics 
should,  the  practical  side  of  the  subject,  and  to  this  end  presents  an  unusually 
large  collection  of  illustrations.  A  great  number  of  these  are  new  and  original, 
and  the  whole  collection  will  form  a  complete  atlas  of  obstetrical  practice. 
An  extremely  valuable  feature  of  the  book  is  the  large  number  of  refer- 
ences to  cases,  authorities,  sources,  etc.,  forming,  as  it  does,  a  valuable  bib- 
liography of  the  most  recent  and  authoritative  literature  on  the  subject 
of  obstetrics.  As  already  stated,  this  work  records  the  wide  practical  ex- 
perience of  the  author,  which  fact,  combined  with  the  brilliant  presentation 
of  the  subject,  will  doubtless  render  this  one  of  the  most  notable  books  on 
obstetrics  that  has  yet  appeared. 

"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the 
first  time.  The  arrangement  of  the  subject-matter,  the  foot-notes,  and  index  are  beyond 
criticism.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never 
necessary  to  re-read  a  sentence  in  order  to  grasp  its  meaning.  As  a  true  model  of  what  ^a 
modern  text-book  in  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's 
book  is  without  a  rival." — New   York  Medical  Record. 


CATALOGUE    OF  MEDICAL    WORKS.  21 

A    TEXT-BOOK    OF    THE    PRACTICE    OF    MEDICINE.      By 

jAiMES  M.  Anders,  M.D.,  I'li.D.,  LL.D.,  Professor  of  the  Practice  of 
Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  College,  Philadel- 
phia. In  one  handsome  octavo  volume  of  1292  pages,  fully  illustrated. 
Cloth,  55.50  net;  Sheep  or  Half- Morocco,  ^6.50  net. 

THIRD   EDITION,  THOROUGHLY   REVISED. 

The  present  edition  is  the  result  of  a  careful  and  thorough  revision.  A  few 
new  subjects  have  been  introduced  :  Glandular  Fever,  Ether-pneumonia,  Splenic 
Anemia,  Meralgia  Paresthetica,  and  Periodic  Paralysis.  The  affections  that 
have  been  substantially  rewritten  are:  Plague,  Malta  Fever,  Diseases  of  the 
Thymus  Gland,  Liver  Cirrhoses,  and  Progressive  Spinal  Muscular  Atrophy. 
The  following  articles  have  been  extensively  revised  :  Typhoid  Fever,  Yellow 
Fever,  Lobar  Pneumonia,  Dengue,  Tuberculosis,  Diabetes  Mellitus,  Gout,  Ar- 
thritis Deformans,  Autumnal  Catarrh,  Diseases  of  the  Circulatory  System,  more 
particularly  Hypertrophy  and  Dilatation  of  the  Heart,  Arteriosclerosis  and 
Thoracic  Aneurysm,  Pancreatic  Hemorrhage,  Jaundice,  Acute  Peritonitis,  Acute 
Yellow  Atrophy,  Hematoma  of  Dura  Mater,  and  Scleroses  of  the  Brain.  The 
preliminary  chapter  on  Nervous  Diseases  is  new,  and  deals  with  the  subject  of 
localization  and  the  various  methods  of  investigating  nervous  affections. 

"  It  is  an  excellent  book — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
— James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  feffer- 
son  Medical  College,  Philadelphia. 

"  The  book  can  be  unreservedly  recommended  to  students  and  practitioners  as  a  safe,  full 
compendium  of  the  knowledge  of  internal  medicine  of  the  present  day  ...  It  is  a  work 
thoroughly  modern  in  every  sense." — Medical  News,  New  York. 

DISEASES  OF  THE  STOMACH.  By  William  W.  Van  Valzah, 
M.  D.,  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  Sys- 
tem and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674  pages, 
illustrated.     Cloth,  $3.50  net. 

An  eminently  practical  book,  intended  as  a  guide  to  the  student,  an  aid  to  the 
physician,  and  a  contribution  to  scientific  medicine.  It  aims  to  give  a  complete 
description  of  the  modern  methods  of  diagnosis  and  treatment  of  diseases  of  the 
stomach,  and  to  reconstruct  the  pathology  of  the  stomach  in  keeping  with  the 
revelations  of  scientific  research.  The  book  is  clear,  practical,  and  complete, 
and  contains  the  results  of  the  authors'  investigations  and  of  their  extensive  ex- 
perience as  specialists.  Particular  attention  is  given  to  the  important  subject  of 
dietetic  treatment.  The  diet-lists  are  very  complete,  and  are  so  arranged  that 
selections  can  readily  be  made  to  suit  individual  cases. 

"This  is  the  most  satisfactory'  work  on  the  subject  in  the  English  language." — Chicago 
Medical  Recorder. 

"  The  article  on  diet  and  general  medication  is  one  of  the  most  valuable  in  the  book,  and 
should  be  read  by  every  practising  physician." — New  York  Medical  Journal. 


22  fV.   B.   SAUNDERS' 


SURGICAL  DIAGNOSIS    AND    TREATMENT.     By   J.  W.    Mao 

DONALD,  M.  D.,  Edin.,  F.  R.  C.  S.,  Edin.,  Professor  of  the  Practice  of  Sur- 
gery and  of  Clinical  Surgery  in  Hamline  University ;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.  Handsome  octavo  volume  of  8oo 
pages,  profusely  illustrated.     Cloth,  $5.00  net;  Half-Morocco,  ^6.00  net. 

This  work  aims  in  a  comprehensive  manner  to  furnish  a  guide  in  matters  of 
surgical  diagnosis.  It  sets  forth  in  a  systematic  way  the  necessities  of  examina- 
tions and  the  proper  methods  of  making  them.  The  various  portions  of  the 
body  are  then  taken  up  in  order  and  the  diseases  and  injuries  thereof  succinctly 
considered  and  the  treatment  briefly  indicated.  Practically  all  the  modern  and 
approved  operations  are  described  with  thoroughness  and  clearness.  The  work 
concludes  with  a  chapter  on  the  use  of  the  Rontgen  rays  in  surgery. 

"  The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cmcinnati  Lancet-Clinic. 

PATHOLOGICAL  TECHNIQUE.     A  Practical  Manual  for  Laboratory 
Work  in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.     By  Frank 
B.  Mallory,  A.  M.,  M.  D.,  Assistant   Professor  of   Pathology,  Harvard 
University  Medical  School,  Boston ;  and  James  H.  Wright,  A.  M.,  M.  D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston.     Oc- 
tavo volume  of  396  pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 
This  book  is  designed  especially  for  practical  use  in  pathological  laboratories, 
both  as  a  guide  to  beginners  and  as  a  source  of  reference  for  the  advanced.   The 
book  will  also  meet  the  wants  oY  practitioners  who  have  opportunity  to  do  general 
pathological  work.     Besides  the  methods  of  post-mortem  examinations  and  of 
bacteriological   and  histological  investigations    connected   with   autopsies,  the 
special  methods   employed  in  clinical  bacteriology  and  pathology  have  been 
fully  discussed. 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology." — 
yournal  of  American  Medical  Association. 

THE  SURGICAL  COMPLICATIONS  AND  SEQUELS  OF  TY- 
PHOID FEVER.     By  Wm.  W.  Keen,  M.'d.,  LL.D.,  Professor  of  the 
Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia.     Octavo  volume  of  386  pages,  illustrated.     Cloth,  ^3.00  net. 
This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject 
of  the  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     The  work  will 
prove  to  be  of  importance  and  interest  not  only  to  the  general  surgeon  and  phy- 
sician, but  also  to  many  specialists — laryngologists,  ophthalmologists,  gynecolo- 
gists, pathologists,  and  bacteriologists — as  the  subject  has  an  important  bearing 
upon  each  one  of  their  spheres.     The  author's  conclusions  are  based  on  reports 
of  over  1700  cases,  including  practically  all  those  recorded  in  the  last  fifty  years. 
Reports  of  cases  have  been  brought  down  to  date,  many  having  been  added 
while  the  work  was  in  press. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader  a 
clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human  organ- 
ism. This  book  should  be  in  the  possession  of  every  medical  man  in  America." — American 
Medico-Surgical  Bulletin. 


CATALOGUE    OF  MEDICAL    WORKS.  23 

MODERN  SURGERY,  GENERAL  AND  OPERATIVE.     By  John 

ChaLxMERS  DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medi- 
cal College,  Philadelphia;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  911  pages,  profusely  illustrated.  Cloth,  %^.QO 
net;   Half-Morocco,  ^5.00  net. 

Second  Edition ,  Rewritten  and  Greatly  Enlarged. 

The  remarkable  success  attending  DaCosta's  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this 
revision  to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines 
that  made  the  former  edition  so  successful.  The  book  has  been  entirely  re- 
written and  very  much  enlarged.  The  old  edition  has  long  been  a  favorite  not 
only  with  students  and  teachers,  but  also  with  practising  physicians  and  sur- 
geons, and  it  is  believed  that  the  present  work  will  find  an  even  wider  field  of 
usefulness. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils  the 
requirements  of  the  modern  student." — Medico-Chiriwgical  Journal,  Bristol,  England. 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery. 
The  book  is  a  valuable  one  which  can  be  recommended  to  students  and  is  of  great  value  to 
the  genera!  practitioner." — Avterican  Journal  of  the  Medical  Sciences. 

A  MANUAL  OF  ORTHOPEDIC  SURGERY.  By  James  E.  Moore, 
M.D.,  Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgeiy.  Octavo  volume 
of  356  pages,  with  177  beautiful  illustrations  from  photographs  made  spec- 
ially for  this  work.     Cloth,  $2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress 
is  laid  upon  early  diagnosis  and  treatment  such  as  can  be  carried  out  by  the 
general  practitioner.  The  teachings  of  the  author  are  in  accordance  with  his 
belief  that  true  conservatism  is  to  be  found  in  the  middle  course  between  the 
surgeon  who  operates  too  frequently  and  the  orthopedist  who  seldom  operates. 

"A  very  demonstrative  work,  every  illustration  of  which  convej's  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  and  Surg'ical  yotir7tal. 

ELEMENTARY   BANDAGING    AND    SURGICAL    DRESSING. 

With  Directions  concerning  the  Immediate  Treatment  of  Cases  of  Emer- 
gency. For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S., 
late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.     Cloth,  flexible  covers,  75  cents  net. 

This  little  book  is  chiefly  a  condensation  of  those  portions  of  Pye's  "  Surgical 
Handicraft"  which  deal  with  bandaging,  splinting,  etc.,  and  of  those  which 
treat  of  the  management  in  the  first  instance  of  cases  of  emergency.  The 
directions  given  are  thoroughly  practical,  and  the  book  will  prove  extremely  use- 
ful to  students,  surgical  nurses,  and  dressers. 

"The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  yournal. 


24  ^   B.   SAUNDERS' 


A    TEXT-BOOK    OF    MATERIA    MEDICA,    THERAPEUTICS 

AND  PHARMACOLOGY.     By  George  F.  Butler,  Ph.G.,  M.D., 
Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians   and    Surgeons,   Chicago ;    Professor  of    Materia    Medica   and 
Therapeutics,    Northwestern    University,  Woman's    Medical    School,   etc. 
Octavo,  874  pages,  illustrated.     Cloth,  $4.00  net;  Sheep,  ^5.00  net. 
Third  Edition^  Thoroughly  Revised, 
A  clear,  concise,  and  practical  text-book,  adapted  for  permanent  reference  no 
less  than  for  the  requirements  of  the  class-room. 

The  recent  important  additions  made  to  our  knowledge  of  the  physiological 
action  of  drugs  are  fully  discussed  in  the  present  edition.  The  book  has  been 
thoroughly  revised  and  many  additions  have  been  made. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory  of  any 
single-volume  works  on  materia  medica  in  the  rndLxkci."  —Jotir?ial  of  the  American  JMedical 
Association. 

TUBERCULOSIS  OF  THE  GENITO-URINARY  ORGANS, 
MALE  AND  FEMALE.  By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,  Chicago.  Handsome  octavo  volume  of  320  pages,  illustrated^ 
Cloth,  ^3.00  net. 

Tuberculosis  of  the  male  and  female  genito-urinary  organs  is  such  a  frequent, 
distressing,  and  fatal  affection  that  a  special  treatise  on  the  subject  appears  to 
fill  a  gap  in  medical  literature.  In  the  present  work  the  bacteriology  of  the  sub- 
ject has  received  due  attention,  the  modern  resources  employed  in  the  differen- 
tial diagnosis  between  tubercular  and  other  inflammatory  affections  are  fully 
described,  and  the  medical  and  surgical  therapeutics  are  discussed  in  detail. 

"An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  importan)-  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

A  TEXT-BOOK  OF  DISEASES  OF  WOMEN.  By  Charles  B. 
Penrose,  M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of 
Pennsylvania;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Octavo 
volume  of  531  pages,  with  217  illustrations,  nearly  all  from  drawings  made 
for  this  work.     Cloth,  $3.75  net. 

Third  Editio^i,  Hevised. 
In  this  work,  which  has  been  written  for  both  the  student  of  gynecology  and 
the  general  practitioner,  the  author  presents  the  best  teaching  of  modern  gyne- 
cology untrammelled  by  antiquated  theories  or  methods  of  treatment.  In  most 
instances  but  one  plan  of  treatment  is  recommended,  to  avoid  confusing  the 
student  or  the  physician  who  consults  the  book  for  practical  guidance. 

"I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women'  received.  I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." — Howard  A.  Kelly,  Professor 
of  Gynecology  atid  Obstetrics ,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the  general 
practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  e.xplained  with  absolute 
clearness." —  Therapeutic  Gazette. 


CATALOGUE    OF  MEDICAL    WORKS.  25 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  John 
Collins  Warren,  M.D.,  LL.D.,  Professor  of  Surgery,  Medical  Depart- 
ment Harvard  University.  Handsome  octavo,  832  pages,  with  136  relief 
and  lithographic  illustrations,  33  of  which  are  printed  in  colors. 

Second  Edition, 

with  an  Appendix  devoted  to  the  Scientific  Aids  to  Surgical  Diagnosis,  and 
a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net;  Half- 
Morocco,  $6.00  net. 

"Without    Exception,  the  Illustrations    are    the  Best  ever  Seen   in    a 

\Vork  of  this  Kind. 

"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  ex- 
ception, from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  *  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their 
coloring  and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the 
barrel  of  a  microscope  at  a  well-mounted  section." — Annah  of  Surgery,  Philadelphia. 

"  It  is  the  handsomest  specimen  of  book-making  *  *  *  that  has  ever  been  issued  from  the 
American  medical  press." — Avierican  Journal  of  the  Medical  Sciences,  Philadelphia. 

PATHOLOGY  AND   SURGICAL  TREATMENT   OF  TUMORS. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College;  Professor  of  Surgery,  Chicago 
Polyclinic ;  Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  New  and  enlarged  Edition 
in  Preparation. 

Books  specially  devoted  to  this  subject  are  few,  and  in  our  iext-books  and 
systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed  to  a  de- 
gree incompatible  with  its  scientific  and  clinical  importance.  The  author  spent 
many  years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains 
to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student, 
a  work  of  reference  for  the  practitioner,  and  a  reliable  guide  for  the  surgeon. 

"The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has 
given  a  notable  and  lasting  contribution  to  surgery." — Journal  of  the  Awerican  Medical 
Association,  Chicago. 

LECTURES    ON    RENAL    AND    URINARY     DISEASES.      By 

Robert  Saundby,  M.  D.,  Edin.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  and  of  the  Royal  Medico-Chirurgical  Society;  Physician  to  the 
General  Hospital.  Octavo  volume  of  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

"The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  e.\pressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  foti-rnal. 


26  14^.   B.   SAUNDERS' 


A  HANDBOOK  FOR  NURSES.  By  J.  K.  Watson,  M.  D.,  Edin., 
Assistant  liouse-Surgeon,  Sheffield  Royal  Hospital.  American  Edition, 
under  the  supervision  of  A.  A.  Stevens,  A.  M.,  M.  D.,  Professor  of 
Pathology,  Woman's  Medical  College,  Philadelphia.  i2mo,  413  pages, 
73  illustrations.     Cloth,  ^1.50  net. 

This  work  aims  to  supply  in  one  volume  that  information  M^iich  so  many 
nurses  at  the  present  time  are  trying  to  extract  from  various  medical  works,  and 
to  present  that  information  in  a  suitable  form.  Nurses  must  necessarily  acquire 
a  certain  amount  of  medical  knowledge,  and  the  author  of  this  book  has  aimed 
judiciously  to  cater  to  this  need  with  the  object  of  directing  the  nurses'  pursuit 
of  medical  information  in  proper  and  legitimate  channels.  The  book  represents 
an  entirely  new  departure  in  nursing  literature,  insomuch  as  it  contains  useful 
information  on  medical  and  surgical  matters  hitherto  only  to  be  obtained  from 
expensive  works  written  expressly  for  medical  men. 

A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Editor  "Cyclopaedia  of  the  Diseases  of  Children,"  etc.;  and 
Henry  Hamilton,  with  the  Collaboration  of  J.  Chalmers  DaCosta, 
M.  D.,  and  Frederick  A.  Packard,  M.  D.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices  :  Cloth,  i^5.oo  net ; 
Sheep  or  Half-Morocco,  ^6.00  net;  vvith  Denison's  Patent  Ready- Refer- 
ence Index ;  without  patent  index,  Cloth,  $4.00  net ;  Sheep  or  Half- 
Morocco,  ^5.00  net. 

PROFESSIOJfAIi   OPIXIOHrS. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
it  to  my  classes." 

Henuy  M.  Lyman,  M.  D., 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.  A.  LiNDSLEY,  M.   D., 

Professor  of  Theory  and  Practice  of  31edicine,  Medical  Dept.  Yale  Uniziersity : 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn^ 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.  Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  and  A.  Haller  Gross,  A.M.,  of  the 
Philadelphia  Bar.  Preceded  by  a  Memoir  of  Dr.  Gross,  by  the  late 
Austin  Flint,  M.  D.,  LL.D.  In  two  handsome  volumes,  each  containing 
over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine  Frontispiece 
engraved  on  steel.     Price  per  Volume,  ^2.50  net. 


CATALOGUE    OF  MEDICAL    WORKS.  2/ 


PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  By  Emily  A,  M.  Sioney,  Graduate  of  the  Training-School 
tor  Nurses,  Lawrence,  Mass. ;  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely 
illustrated  with  73  engravings  in  the  text,  and  9  colored  and  half-tone 
Dlates.     Cloth.     Price,  $i.7.S  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  o{  p7'ivate  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

An  especially  valuable  feature  of  the  work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fre- 
quently extreme. 

"I'he  work  has  been  logically  divided  into  the  following  sections : 

I.  The  Nurse :  her  responsibilities,  qualifications,  equipment,  etc. 
IL  The  Sick-Room  :  its  selection,  preparation,  and  management. 
/II.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  and  gyne- 
cologic cases. 
IV.  Nursing  in  Accidents  and  Emergencies. 
•  V.  Nursing  in  Special  Medical  Cases. 
VI.  Nursing  of  the  New-born  and  vSick  Children. 
VII.  Physiology  and  Descriptive  Anatomy, 

The  Appendix  contains  much  information  m  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick;  Recipes  for 
Invalid  Foods  and  Beverages  ;  Tables  of  Weights  and  Measures ;  Table  for 
Computing  the  Date  of  Labor;  List  of  Abbreviations ;  Dose-List;  and  a  full 
and  complete  Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Jou7-nal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  Aug.,  i8g6. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiology  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and  Moulds, 
Hsematozoa,  and  Psorosperms.  By  Edgar  M.  Crookshank,  M.  B.,  Pro- 
Tessor  of  Comparative  Pathology  and  Bacteriolog}%  King's  College,  London. 
A  handsome  octavo  volume  of  700  pages,  with  273  engravings  in  the  text, 
and  22  original  and  colored  plates.     Price,  S6.50  net. 

This  book,  though  nominally  a  Fourth  Edition  of  Professor  Crookshank's 
"  Manual  of  Bacteriology,"  is  practically  a  new  work,  the  old  one  having 
been  reconstructed,  greatly  enlarged,  revised  throughout,  and  largely  rewritten, 
forming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Olhcers  of 
Health,  and  for  Veterinary  insoecioiri.- 


28  PV.  B.    SAUNDERS' 


MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Fifth  Enlarged  German  Edition,  with  the  author's  permission,  by 
Francis  H.  Stuart,  A.  M.,  M.  D.  In  one  handsome  royal-octavo  volume 
of  600  pages.  194  fine  wood-cuts  m  the  text,  many  of  them  in  colors. 
Prices:  Cloth,  ^4.00  net;   Sheep  or  Half- Morocco,  ^5.00  net. 

FOURTH  AMERICAN  EDITION,  FROM  THE  FIFTH  REVISED  AND 
ENLARGED  GERMAN  EDITION. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as  a 
factor  in  the  origin  of  disease. 

The  present  edition  of  this  highly  successful  work  has  been  translated  from 
the  fifth  German  edition.  Many  alterations  have  been  made  througliout  the 
book,  but  especially  in  the  sections  on  Gastric  Digestion  and  the  Nervous  System. 

It  will  be  found  that  all  the  qualities  which  served  to  make  the  earlier  editions 
so  acceptable  have  been  developed  with  the  evolution  of  the  work  to  its  present 
form. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J,  J.  Pringle,  M.  B.,  F,  R.  C,  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromes  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  ^3.00  per  Part. 

"  Of  all  the  atlases  of  skin  diseases  which  have  been  published  in  recent  years,  the  present 
one  promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the 
general  practitioner." — American  Medico-Surgical  Bulletin,  Feb.  22,  1896. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal ,  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture 
by  the  physician  who  treated  the  case  or  at  whose  instigation  the  models  have  been  made. 
We  predict  for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world 
where  the  names  St.  Louis  and  Baretta  have  preceded  it." — Medical  Record,  N.  Y.,  Feb.  i, 
1896. 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (MASSAGE  AND 
MEDICAL  GYMNASTICS).  By  Axel  V.  Grafstrom,  B.  Sc, 
M.  D.,  late  Lieutenant  in  the  Royal  Swedish  Army;  late  House  Physi- 
cian, City  Hospital,  Blackwell's  Island,  New  York.  i2mo,  139  pages, 
illustrated.     Cloth,  ^i.oo  net. 


CATALOGUE    OF  MEDICAL    WORKS. 


DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology  in 
the  Jefferson  Medical  College,  Philadelphia,  etc.  A  handsome  royal- 
octavo  volume  of  696  pages,  with  255  fine  illustrations,  many  of  which  are 
original,  and  2  chromo-lithographic  plates.  Prices :  Cloth,  $4.00  net ; 
Sheep  or  Half- Morocco,  $5.00  net. 

THIRD  EDITION,  THOROUGHLY  REVISED. 

In  the  third  edition  of  this  text-book,  destined,  it  is  hoped,  to  meet  the  favor- 
able reception  which  has  been  accorded  to  its  predecessors,  the  work  has  been 
revised  thoroughly,  and  much  new  matter  has  been  introduced.  Particular 
attention  has  been  given  to  the  important  relations  which  micro-organisms  bear 
to  many  ocular  diseases.  A  number  of  special  paragraphs  on  new  subjects  have 
been  introduced,  and  certain  articles,  including  a  portion  of  the  chapter  on 
Operations,  have  been  largely  rewritten,  or  at  least  materially  changed.  A 
number  of  new  illustrations  have  been  added.  The  Appendix  contains  a  full 
description  of  the  method  of  determining  the  corneal  astigmatism  with  the 
ophthalmometer  of  Javal  and  Schiotz,  and  the  rotation  of  the  eyes  with  the 
tropometer  of  Stevens. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M.  D. 

Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 

in  the  University  of  Pennsylvania. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon 
the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology,  it  is  the  best  single  volume  at  present  published." — Medical  Ne^us. 

"It  is  a  very  useful,  satisfactory,  and  safe  guide  for  the  student  and  the  practitioner,  and 
one  of  the  best  works  of  this  scope  in  the  English  language." — Annals  of  Ophthab)iology. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.R.  C.  S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital,  London  ; 
and  Arthur  E.  Giles,  M.  D.,  B.  Sc,  Lond.,  F.  R.C.  S.,  Edin.,  Assistant 
Surgeon  to  Chelsea  Hospital,  London,  436  pages,  handsomely  illustrated. 
Cloth,  $2.50  net. 

The  authors  have  placed  in  the  hands  of  the  physician  and  student  a  concise 
yet  comprehensive  guide  to  the  study  of  gynecology  in  its  most  modern  develop- 
ment. It  has  been  their  aim  to  relate  facts  and  describe  methods  belonging  to 
the  science  and  art  of  gynecology  in  a  way  that  will  prove  useful  to  students  for 
examination  purposes,  and  which  will  also  enable  the  general  physician  to  prac- 
tice this  important  department  of  surgery  with  advantage  to  his  patients  and  with 
satisfaction  to  himself. 

"  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical  public." 
— British  Medical  Journal. 

"  The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  d'a.y."— Journal  of  the 
American  Medical  Association. 


30  m:   £.   SAUNDEKS' 


TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA,  bpe- 
cially  written  for  Students  of  Medicine.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia,  etc.     497  pages,  finely  illustrated.     Price,  Cloth, 

^2.50  net. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED. 

The  work  is  intended  to  be  a  text-book  for  the  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory  training  in  this  department  of  medi- 
cal science.  The  instructions  given  as  to  needed  apparatus,  cultures,  stainings, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  afford 
to  the  physician  much  information  that  will  interest  and  profit  him  relative  to  a 
subject  which  modern  science  shows  to  go  far  in  explaining  the  etiology  of  many 
diseased  conditions. 

In  this  second  edition  the  work  has  been  brought  up  to  date  in  all  depart- 
ments of  the  subject,  and  numerous  additions  have  been  made  to  the  technique 
in  the  endeavor  to  make  the  book  fulfil  the  double  purpose  of  a  systematic  work 
upon  bacteria  and  a  laboratory  guide. 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 
useful  to  those  for  whom  it  is  written. — London  Lancet,  Aug.  29,  1896. 

"  The  author  has  succeded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  with  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking 
students  of  medicine." — N.  Y.  Medical  Journal,  April  4,  1896, 

"  The  book  will  be  found  of  considerable  use  by  medical  men  who  have  not  had  a  special 
bacteriological  training,  and  who  desire  to  understand  this  important  branch  of  medical 
science." — Edinburgh  Medical  Journal,  July,  iSyfe. 

LABORATORY    GUIDE    FOR    THE    BACTERIOLOGIST.      By 

Langdon  Frothingham,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veteri- 
nary Science,  Sheffield  Scientific  School.  Yale  University.  Illustrated. 
Price,  ClotJti,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  ana 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  work, 

"It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  necessary 
for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking  up  the 
various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages.'' — Jimerican  Mea.' 
Surg.  Bulletin. 

FEEDING  IN  EARLY  INFANCY.  By  Arthur  V.  Meigs,  M.  D. 
Bound  in  limp  cloth;  flush  edges.     Price,  25  cents  net. 

Synopsis  :  Analyses  of  Milk — Importance  of  the  Subject  of  Feeding  in  Early 
Infancy — Proportion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administered  at  Each  Feed- 
ing— Intervals  between  Feedings — Increase  in  Amount  of  Food  at  Different 
Periods  of  Infant  Development — Unsuitableness  of  Condensed  Milk  as  a  Sub- 
stitute for  Mother's  Milk — Objections  to  Sterilization  or  "Pasteurization"  oi 
Milk — Advances  made  in  the  Method  of  ArUficial  Feeding  of  Infants. 


CATALOGUE    OF  MEDICAL    WORKS.  3 1 

MATERIA    MEDICA    FOR    NURSES.     By  Emily    A.  M.   Stoney, 

Graduate  of  the  Training-school  for  Nurses,  Lawrence,  Mass. ;  late 
Superintendent  of  the  Training-school  for  Nurses,  Carney  Hospital,  South 
Boston,  Mass.     Handsome  octavo,  300  pages.     Cloth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in -several  features,  all  of 
which  are  introduced  to  render  it  more  practical  and  generally  useful.  The 
general  plan  of  contents  follows  the  lines  laid  down  in  training-schools  for 
nurses,  but  the  book  contains  much  useful  matter  not  usually  included  in  works 
of  this  character,  such  as  Poison-emergencies,  Ready  Dose-list,  Weights  and 
Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms  in  Materia  Medica, 
and  describing  all  the  latest  drugs  and  remedies,  which  have  been  generally 
neglected  by  other  books  of  the  kind. 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Hints  on  Dissection."  By  Charles 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy ;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  lost  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  ^2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscle^ 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy, 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Professor  of  Pathology  in  the  Woman's  Medical  College  of 
Pennsylvania.  vSpecially  intended  for  students  preparing  for  graduation 
and  hospital  examinations.  Post  8vo,  519  pages.  Numerous  illustrations 
and  selected  formulas.     Price,  bound  in  flexible  leather,  $2.00  net. 

FIFTH  EDITION,  REVISED  AND  ENLARGED. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
Jast  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
hmiied  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac* 
tice  of  medicine. 


32  W.   B.   SAUNDERS' 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

By  A,  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Professor  of  Pathology  in  the  Woman's 
Medical  College  of  Pennsylvania.  445  pages.  Price,  bound  in  flexible 
leather,  ^2.25. 

SECOND   EDITION,    REVISED. 

This  wholly  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copoeia, comprehends  the  following  sections  :  Physiological  Action  of  Drugs ; 
Drugs;  Remedial  Measures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility in  Prescriptions ;  Table  of  Doses ;  Index  of  Drugs ;  and  Index  of 
Diseases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare." —  Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class  ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Journal. 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  ,  . 
and  it  will  be  found  a  reliable  guide." — University  Medical  Magazitie. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  David  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  253  pages.     Price,  #1.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY  ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE  CHART.     Prepared  by  D.  T.  Laine,  M.  D.      Size 
8x  llYz  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE    OF  MEDICAL    WORKS. 


A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  Arthur  Clarkson,  M.  B., 
C.  M.,  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
^4.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tology, in  one  volume,  with  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  general 
methods  of  Histology  ;  subsequently,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systematically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
methods  of  preparation. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text-books,  and 
is  to  be  highly  recommended." — Ne^u  York  Medical  Journal. 

"  One  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the  book  will 
attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

THE  PATHOLOGY  AND  TREATMENT  OF  SEXUAL  IM- 
POTENCE. By  Victor  G.  Vecki,  M.  D.  From  the  second  Ger- 
man edition,  revised  and  rewritten.  Demi-octavo,  about  300  pages. 
Cloth,  $2.00  net. 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  it  deserves,  and  this  volume  will  come  to  many  as  a 
revelation  of  the  possibilities  of  therapeusis  in  this  important  field.  Dr.  Vecki's 
work  has  long  been  favorably  known,  and  the  German  book  has  received  the 
highest  consideration.  This  edition  is  more  than  a  mere  translation,  for,  although 
based  on  the  German  edition,  it  has  been  entirely  rewritten  by  the  author  in 
English. 

"  The  work  can  be  recommended  as  a  scholarly  treatise  on  its  subject,  and  it  can  be  read 
with  advantage  by  many  practitioners." — Jozirnal  of  the  American  Medical  Association. 

THE  TREATMENT  OF  PELVIC  INFLAMMATIONS 
THROUGH  THE  VAGINA.  By  W.  R.  Pryor,  M.  D.,  Pro- 
fessor of  Gynecology  in  the  New  York  Polycliiiic.  i2mo,  248  pages, 
handsomely  illustrated.     Cloth,  $2.00  net. 

In  this  book  the  author  directs  the  attention  of  the  general  practitioner  to  a 
surgical  treatment  of  the  pelvic  diseases  of  women.  Tliere  exists  the  utmost 
confusion  in  the  profession  regarding  the  most  successful  methods  of  treating 
pelvic  inflammation?  ;  and  inasmuch  as  inflammatory  lesions  constitute  the  ma- 
jority of  all  pelvic  diseases,  the  subject  is  an  important  one.  It  has  been  the 
endeavor  of  the  author  to  put  down  every  little  detail,  no  matter  how  insig- 
nificant, which  might  be  of  service. 


34  ^^'    ^-    SAUNDERS' 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.  D., 
Professor  of  Gynecology  in  the  New  York  School  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  In  one  handsome  octavo  volume  of  728  pages,  illustrated  by 
335  engravings  and  colored  plates.  Prices:  Cloth,  $4.00  net;  Sheep  or 
Half-'Morocco,  $5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  anatotny 
of  \h.t.  female  genitalia^  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

Second  EditioUf  Thoroughly  Revised, 

The  first  edition  of  this  work  rnet  with  a  most  appreciative  reception  by  the 
medical  press  and  profession  both  in  this  country  and  abroad,  and  was  adopted 
as  a  text-book  or  recommended  as  a  book  of  reference  by  nearly  one  Jnmdred 
colleges  in  the  United  States  and  Canada.  The  author  has  availed  himself  of 
the  opportunity  afforded  by  this  revision  to  embody  the  latest  approved  advances 
in  the  treatment  employed  in. this  important  branch  of  Medicine.  He  has  also 
more  extensively  expressed  his  own  opinion  on  the  comparative  value  of  the 
different  methods  of  treatment  employed. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  booVc  invaluable  counsel  and  help." 

Thad.  a.  Reamy,  M.  D.,  LL.D., 

Professor  of  Clinical  Gynecology ,  Medical  College  of  Ohio ;   Gynecologist  to  the  Good 

Samaritan  and  Cincinnati  Hospitals. 


A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  ^i.oo  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  ^resented  in  a  manner  at  once  systematic,  clear,  succinct, 
pnd  practica.1. 


CATALOGUE    OF  MEDICAL    WORKS.  35 


THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited 
by  W.  A.  Newman  Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 
of  the  University  of  Pennsylvania;  Fellow  of  the  American  Academy  of 
Medicine.  Containing  the  pronunciation  and  definition  of  all  the  principal 
words  used  in  medicine  and  the  kindred  sciences,  with  64  extensive  tables. 
Handsomely  bound  in  flexible  leather,  limp,  with  gold  edges  and  patent 
thumb  index.     Price,  $1.00  net ;  with  thumb  index,  ^1.25  net. 

SECOND  EDITION,  REVISED. 

This  is  the  ideal  pocket  lexicon.  It  is  an  absolutely  new  book,  and  not  a  re- 
vision of  any  old  work.  It  is  complete,  defining  all  the  terms  of  modern  medi- 
cine and  forming  an  unusually  complete  vocabulaiy.  It  gives  the  pronunciation 
of  all  the  terms.  It  makes  a  special  feature  of  the  newer  words  neglected  by 
other  dictionaries.  It  contains  a  wealth  of  anatomical  tables  of  special  value  to 
students'.     It  forms  a  handy  volume,  indispensable  to  every  medical  man. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1800  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  morocco,  with  side  index,  wallet,  and  flap.  Price,  $1.75 
net. 

FIFTH  EDITION,  THOROUGHLY  REVISED. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given, is  unusually  reliable." — New  Yo7-k  Medical  Record. 

A  COMPENDIUM  OF  INSANITY.  By  John  B.  Chapin,  M.D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  late  Physician- 
Superintendent  ofthe  Willard  State  Hospital,  New  York ;  Honorary  Mem- 
ber of  the  Medico- Psychological  Society  of  Great  Britain,  of  the  Society  of 
Mental  Medicine  of  Belgium.      i2mo,  234  pages,  illust.     Cloth,  $1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of 
Diseases  of  the  ISIind,  for  the  convenient  use  and  aid  of  physicians  and  students. 
It  contains  a  clear,  concise  statement  of  the  clinical  aspects  of  the  various  ab- 
normal rnental  conditions,  with  directions  as  to  the  most  approved  methods  of 
managing  and  treating  the  insane. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  We 
desire  especially,  however,  to  call  atti^ntion  to  the  fact  that  in  the  subject  ofthe  therapeutics 
of  insanity  the  work  is  exceedingly  valuable.  The  author  has  made  a  distinct  addition  to  the 
literature  of  his  specialty." — Philadelphia  Medical  Journal. 


36  W.   B.   SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired  in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used — viz.  general  instru 
ments,  etc.,  required  for  all  operations ;  and  special  instruments  for  surgery  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  femals 
genito-urinary  organs,  the  bones,  etc. 

The  v^'hole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — New  Yotk  ISIedical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — Ajnerican  Lancet. 

"  The  plan  is  a  capital  one." — Boston  Medical  and  Surgical  Journal. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  $2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

"  There  is  no  vi^ork  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country,  and 
we  predict  for  it  a  wide  circulation." — American  Joziynal  of  Pharmacy. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  Mrs.  Ernest  Hart, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages;  illustrated.  Price, 
Cloth,  ^1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  special 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  them  trouble  in  directing  the  dietetic 
treatment  of  patients. 


CATALOGUE    OF  MEDICAL    WORKS.  37 


A.  MANUAL    OF    PHYSIOLOGY,  with    Practical    Exercises.     For 

Students  and  Practitioners.    By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc, 

lately  Examiner  in   Physiolog)%  University  of  Aberdeen,  and  of  the  New 

Museums,  Cambridge  University ;   Professor  of  Physiology  in  the  Western 

Reserve  University,  Cleveland,  Ohio.     Handsome  octavo  volume  of  848 

pages,  with  300  illustrations  in  the  text,  and  5  colored  plates.     Price,  Cloth, 

$3.75  net. 

THIRD  EDITION,  REVISED. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deseirves  to  do  so.     It  is  one  oj 
the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearly 
comes  up  to  the  ideal  as  does  Professor  Stewart's  volume." — British  Medical  Journal. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Corwix,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diagno- 
sis in  the  Rush  Medical  College,  Chicago;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  219  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  Si. 25  net. 

THIRD  EDITION,  THOROUGHLY  REVISED  AND  ENLARGED. 
SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Third  edition,  thoroughly  revised  and  enlarged.  Crown 
8vo.     Price,  Cloth,  interleaved  for  notes,  $2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not aflford  to  despise." — New  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  "  An  American  Text-Book 
of  Surgery."  By  X.  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surger}^  in  Rusl 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  $2.00, 

This  work  by  so  eminent  an    author,  himself   one  of   the    contributors   to  ^, 
*'  An  American  Text-Book  of   Surgery,"  will    prove  of  exceptional   value   to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.     It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehen- 
sive, and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full 
references  are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology." — British 
Medical  Journal,  London. 


38  IV.   B.   SAUNDERS' 


THE   CARE   OF   THE    BABY.      By  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
.  Physician  to  the  Children's  Hospital',  Philadelphia,  etc.     404  pages,  with 
67  illustrations  in  the  text,  and  5  plates.      i2mo.     Price,  $1.50. 

SECOND  EDITION,  REVISED. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  mas- 
ter  hand.  _  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by 
:iny  practitioners  who  have  not  had  large  opportunities  for  observing  children." — Ajnerican 
yjurnal  of  Obstetrics. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  the  sick-room.  By  HoNNOR 
Morten,  author  of  "  How  to  Become  a  Nurse,"  *'  Sketches  of  Hospital 
Life,"  etc.      i6mo,  140  pages.     Price,  Cloth,  $1.00. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physicia-n  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital ;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  ^1.50    (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Ansemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric- Acid  Diathesis,  Obesity,  and  Tuberculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessary  for  invalids.  Each  list  is  nu7nbered  only,  the 
disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  Starr,  M.  D.,  Editor  of  "  An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
perforated  and  neatly  bound  in  flexible  morocco.     Price,  ^1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula 
toT   tfle  preparation  of  diluents  and  foods  are  appended. 


CATALOGUE   OF  MEDICAL    WORKS.  39 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Paediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
by  Dr.  McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate 
the  text.     Third  edition.      Price,  Cloth,  ^2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  e.xamining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  News,  Philadelphia. 

NURSING:    ITS    PRINCIPLES    AND    PRACTICE.      By   Isabel 

Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  512 
pages,  illustrated.     Price,   Cloth,  $2.00  net. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowliidge  of  the  care  of  the  sick 
and  the  hygiene  of  the  sick-room. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  Boisliniere,  M.  D.,  late  Emeritus  Professor  of 
Obstetrics  in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.    Price,  ;^2.oo  net. 

"  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 
opportunity  of  con.sulting  a  library  or  of  calling  a  friend  in  consultation.  He 
then,  being  thrown  upon  his  own  resources,  will  find  this  book  of  benefit  in 
guiding  and  assisting  him  in  emergencies." 

INFANT'S  WEIGHT  CHART.  Designed  by  J.  P.  Crozer  Grjffith, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn? 
sylvania.    25  charts  in  each  pad.     Price  per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first 
two  years  of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight 
of  a  healthy  infant,  so  that  any  deviation  from  the  normal  can  readily  be  detected 


Saunders^ 
New  Series 
OF  Manuals 


for  Students 
and 
Practitioners* 


THAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading 
branches  of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the 
favor  with  which  the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been 
received  by  medical  students  and  practitioners  and  by  the  Medical  Press. 
These  manuals  are  not  merely  condensations  from  present  literature,  but 
are  ably  w^ritten  by  well-known  authors  and  practitioners,  most  of  them  being 
Jeachers  in  representative  American  colleges.  Each  volume  is  concisely  and 
authoritatively  written  and  exhaustive  in  detail,  without  being  encumbered 
with  the  introduction  of  "cases,"  which  so  largely  expand  the  ordinary  text- 
book. These  manuals  will  therefore  form  an  admirable  collection  of  advanced 
lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the  latter, 
too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value  ;  to  the  former  they  will 
afford  safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be 
superior  to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so 
much  information  in  such  a  concise  and  available  form.  A  liberal  expenditure 
has  enabled  the  publisher  to  render  the  mechanical  portion  of  the  work  worthy 
of  the  high  literary  standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page 
for  List). 


SAUNDERS'  NEW  SERIES  OE  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.  M.,  M.  D.,  Professor 
of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College   Hospital,  etc.     Price,  ^1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D.,  Professor  of  Clinical  Surgen.',  Jefiferson  Medical  College,  Philadel- 
phia. Second  edition,  revised  and  greatly  enlarged.  Octavo,  911  pages, 
386  illustrations.     Cloth,  34-00  net ;   Half-Morocco,  $5.00  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,    M.  D.,  Demonstrator   of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  ^1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc      Price,  ^1.50  net.     ' 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  $1.25  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.  D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.     Price,  S2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinaiy  Diseases   in  Rush  Medical  College,  Chicago.     Price,  ^$2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  New  York 
Infirmary,  etc.     Price,  $2.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological 
Dispensary,  Pennsylvania  Hospital.     Price,  $2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 
Surgeon  to  the  Middlesex  Hospital,  and  Surgeon  to  the  Chelsea  Hospital 
for  Women,  London;  and  Arthur  E.  Giles,  M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S. 
Edin.,  Assistant  Surgeon  to  the  Chelsea  Hospital  for  Women,  London.  436 
pages,  handsomely  illustrated.     Price,  $2.50  net. 

IN    PREPARATION. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Profes- 
sor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

*:::*  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully  prepared  works 
on  various  subjects,  by  prominent  specialists. 

41 


SAUNDERS'  QUESTION  COMPENDS 

Arranged  in  Question  and  Answer  Form. 


THE  LATEST,  MOST  COMPLETE,  and  BEST  ILLUSTRATEE 
SEEIES  OF  COMPENDS  EVEE  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


WITH 


Students  and  Practitioners  in  every  City  of  the  United 
States  and  Canada. 


THE   REASON   WHY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  DO  HELP;  they  are 
the  leaders  in  their  special  line,  well  atid  authoritatively  w^'itten  by  able  men^ 
who,  as  teachers  in  the  large  colleges,  know  exactly  zvhat  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  twenty-four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessary,  many  of  them  being  in  their  fourth  and 
fiifth  editions. 

TO    SUM    UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

*:i:*  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  next 

page  for  List). 

42 


SAUNDERS'  QUESTION-COMPEND  SERIES. 


2.   ESSENTIALS  OF  SURGERY 

iratioiis. 


Price,  doth,  $L00  per  copy,  except  when  otherwise  noted. 

1.  ESSENTIALS  OF  PHYSIOLOGY.  4th  edition.  Illustrated.  Revised  and  enlarged 
By  H.  A.  Hake,  iM.  1).     (I'nce,  ;^i.oo  net.)  ^     ' 

3  OF  SURGERY.    7th  edition,  with  .t  cliaptcr  on  Appendicitis.    90  illus- 
IJy  IIduaku  iMaktin,  M.  D.  (Price,  $i.oo  net.) 

3.  ESSENTIALS  OF  ANATOMY.     6th  edition,  thoroughly  revised.     151  illustrations. 

P>y  Charles  B.  Nanckede,  IM.  D.     (Price,  $1.00  net.) 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

5th  edition,  revised,  with  an  Appendix.     By  Lawkence  Wolff,  M.  D.     ($1.00  net.) 

5.  ESSENTIALS  OF  OBSTETRICS.     4th  edition,  revised  and  enlarged.      75  illustra- 

tions.    By  \V.  Easterly  Ashton,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     7th  thousand. 

46  illustrations.     By  C.  E.  Akmand  Semple,  M.  D. 

7.  ESSENTIALS    OF    MATERIA      MEDICA,     THERAPEUTICS,    AND    PRE- 

SCRIPTION-WRITING.     5th  edition.      By  Henry  xMorris,  M.  D. 

8,9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.  By  Henry  Morris,  M.  D. 
An  Appendix  on  Urine  Examin  ation.  Illustrated.  By  Lawrence  Wolff',  M.  D. 
3d  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authori- 
tie.s,  by  Wm.  M.  Powell,  M.  D.     (Double  number,  price  ^2.00.) 

10.  ESSENTIALS  OF  GYNAECOLOGY.     4th  edition,  revised.     With  62  illustrations. 

By  Edwin  B.  Cragin,  M.  D. 

11.  ESSENTIALS  OF  DISEASES  OF    THE  SKIN.  4th  edition,  revised  and  enlarged. 

71  letter-press  cuts  and  15  half-tone  illustrations.    By  Henry  W.  Stelwagon,  M.D. 
(Price,  ^i.oo  net.) 

12.  ESSENTIALS  OF  MINOR    SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     2d    edition,   revised    and    enlarged.     78   illustrations.      By  Edward 
:Martin,  M.  D. 

13.  ESSENTIALS  OF  LEGAL    MEDICINE,  TOXICOLOGY,  AND    HYGIENE. 

130  illustrations.     By  C.  E.   Armand  Semple,  i\I.  D. 

14.  ESSENTIALS  OF  DISEASES  OF   THE  EYE,  NOSE,  AND  THROAT.    124 

illustrations.     2d  edition,  revised.     By  Edward  Jackson,  M.  D.,  and  E.  Baldwin 
Gleason,  M.  D. 

15.  ESSENTIALS  OF   DISEASES   OF  CHILDREN.     2d  edition.     By  William  M 

Powell,  M.  D. 

16.  ESSENTIALS  OF  EXAMINATION    OF    URINE.      Colored   "  Vogel  Scale," 

and  numerous  illustrations.      By   Lawrence  Wolff,  M.  D.     (Price,  75  cents.) 

17.  ESSENTIALS  OF  DIAGNOSIS.     2d  edition,  thoroughly  revised.     60  illustrations. 

By  S.  Solis-Cohen,  iM.  D.,  and  A.  A.  Eshner,  M.  D.     (Price,  $t.oo  net.) 

18.  ESSENTIALS  OF   PRACTICE  OF  PHARMACY.     2d  edition,  revised.     By  L. 

E.  Sayre. 

20.  ESSENTIALS  OF   BACTERIOLOGY.      3d    edition.     82    illustrations.     By  M.  V. 

Ball,  M.  D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.    48  illustrations. 

3d  edition,  revised.     By  John  C.  Shaw,  I\1.  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.     155  illustrations.     2d  edition,  revised. 

By  Fred  J.  Brockway,  J\I.  D.     (Price,  $1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations.     By  David  D. 

Stewart,  M.  D.,  and  Edward  S.  Lawrance,  M.  D. 

34.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.     114  illustrations.    2d  edition,  re- 
vised  and  enlarged.     By  E.  Baldwin  Gleason,  M.  D. 

43 


Some  of  the  Books  in  Preparation  for 
Publication  during  1900. 


AMERICAN  Text=Book  of  Pa= 
thology. 

Edited  by  Ludvig  Hektoen,  M.D.,  Pro- 
fessor of  Patliology,  Rush  Medical  College, 
Chicago;  and  Daviu  Riesrian,  M.D.,  De- 
monstrator of  Pathological  Histology,  Uni- 
versity of  Pennsylvania. 

AMERICAN  Text=Book  of  Legal 
Medicine  and  Toxicology. 

Edited  by  Frederick  Peterson,  M.D., 
Chief  of  Clinic,  Nervous  Department,  College 
of  Physicians  and  Surgeons,  New  York  City  ; 
and  Walter  S.  Haines,  M.D.,  Professor  of 
Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  Chicago. 

BECK— Fractures. 

By  Carl  Beck,  M.D.,  Professor  of  Surgery 
in  the  N.  Y.  School  of  Clinical  Medicine. 

BOHM,  DAVIDOFF,  and  HU= 
BER— A  Text=Book  of  Human 
Histology. 

Including  Microscopic  Technic.  By 
Dr.  a.  a.  Bohm  and  Dr.  M.  von  Davidoff, 
of  the  Anatomical  Institute  of  Munich,  and 
G.  C.  Hueer,  M.D.,  Junior  Professor  of  Anat- 
omy and  Histology,  University  of  Michigan, 
Ann  Arbor. 

EICHHORST— A  Text=Book  of 
the  Practice  of  Medicine. 

P>y  Dr.  Herman  Eichhorst,  Professor  of 
Special  Pathology  and  Therapeutics  and  Di- 
rector of  the  Medical  Clinic,  University  of 
Zurich.  Translated  and  edited  by  Augustus 
A.  Eshner,  M.D  ,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic. 

FRIEDRICH  —  Rhinology,  La= 
ryngology,  and  Otology  in 
their  Relations  to  General 
Medicine. 

By  Dr.  E.  P.  Friedrich,  of  the  Univer- 
sity of  Leipsig. 

LEVY  AND  KLEMPERER  — 
The  Elements  of  Clinical  Bac= 
teriology. 

By  Dr.  Ernst  Levy,  Professor  in  the 
University  of  Strassburg,  and  Dr.  Felix 
Klemperer,  Privat-Docent  in  the  Univer- 
sity of  Strassburg.  Translated  and  edited 
by  Augustus  A.  Eshner,  M.D.,  Professor 
of  Clinical  Medicine  in  the  Philadelphia  Poly- 
clinic.   Just  Ready.     Cloth,  %2.  5c  net. 


McFARLAND— A  Text=Book  of 
Pathology. 

By  Joseph  McFarland,  M.D.,  Professor 
of  Pathology  and  Bacteriology,  Medico-Chi- 
rurgical  College,  Philadelphia. 

OGDEN  —  Clinical  Examination 
of  the  Urine. 

By  J.  Bergen  Ogden,  M.D.,  A.ssistant  in 
Chemistry,  Harvard  Medical  School. 

PYLE— A  Manual  of  Personal 
Hygiene. 

Edited  by  Walter  L.  Pyle,  M.D.,  Assis- 
tant Surgeon  to  Wills'  Eye  Hospital,  Philada. 

SCUDDER— The  Treatment  of 
Fractures. 

By  Charles  L.  Scudder,  M.D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard 
University. 

SENN— Practical  Surgery. 

By  Nicholas  Senn,  M.D.,  Ph.D.,LL.D,. 
Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. Octavo  volume  of  about  800  pages, 
profusely  illustrated. 

The  Pathology  and  Treatment 
of  Tumors. 

By  Nicholas  Senn,  M.D..  Ph.D.,LL.D., 
Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. A  New  and  Ihoroughly  Revised  Edi- 
tion in  preparation. 

STENGEL  AND  WHITE  — The 
Blood  in  its  Clinical  and  Patho= 
logical  Relations. 

V>y  Alfred  Stengel,  M.D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsyl- 
vania; and  C.  Y.  White,  M.D.,  Instruc- 
tor in  Clinical  Medicine,  University  of  Penn- 
sylvania. 

STEVENS— The  Physical  Diag= 
nosis  of  Diseases  of  the  Chest. 

By  A.  A.  Stevens,  A.M.,  M.D.,  Lecturer 
on  Terminology,  and  Instructor  in  Physical 
Diagnosis,  University  of  Pennsylvania. 

STONE Y  —  Surgical  Technique 
for  Nurses. 

By  Emily  A.  M.  Stoney,  late  Superin- 
tendent of  the  Training  Schools  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass. 


44 


SAUNDERS' 

MEDICAL  HAND-ATLASES. 

The  series  of  books  included  under  this  title  are  authorized  tranislations 
into  English  of  the  world-famous 

Lehmann  Mcdicinische  Handatlanten, 

which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and 
cheapness  surpass  any  similar  volumes  ever  published. 

Each  volume  contains  from  50  to  100  colored  plates,  besides  numer- 
ous illustrations  in  the  text.  The  colored  plates  have  been  executed  by  the 
most  skilful  German  lithographers,  in  some  cases  more  than  twenty  im- 
pressions being  required  to  obtain  the  desired  result.  Each  plate  is  accom- 
panied by  a  full  and  appropriate  description,  and  each  book  contains  a  con- 
densed but  adequate  outline  of  the  subject  to  which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  atlases  is  that  they  offer  a 
ready  and  satisfactory  substitute  for  clinical  observation.  Such  ob- 
servation, of  course,  is  available  only  to  the  residents  in  large  medical  centers; 
and  even  then  the  requisite  variety  is  seen  only  after  long  years  of  routine 
hospital  work.  To  those  unable  to  attend  important  clinics  these  books 
will-  be  absolutely  indispensable,  as  presenting  in  a  complete  and  con- 
venient form  the  most  accurate  reproductions  of  clinical  work,  interpreted 
by  the  most  competent  of  clinical  teachers. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has 
heretofore  been  practically  debarred  from  purchasing  similar  works  because 
of  their  extremely  high  price,  made  necessary  by  a  limited  sale  and  an 
enormous  expense  of  production.  Now,  however,  by  reason  of  their  pro- 
jected universal  translation  and  reproduction,  affording  international  dis- 
tribution, the  publishers  have  been  enabled  to  secure  for  these  atlases  the 
best  artistic  and  professional  talent,  to  produce  them  in  the  most 
elegant  style,  and  yet  to  offer  them  at  a  price  heretofore  unapproached 
in  cheapness.  The  great  success  of  the  undertaking  is  demonstrated 
by  the  fact  that  the  volumes  have  already  appeared  in  thirteen  different 
languages — German,  English,  French,  Italian,  Russian,  Spanish,  Dutch, 
Japanese,  Danish,  Swedish,  Roumanian,  Bohemian,  and  Hungarian. 

The  same  careful  and  competent  editorial  supervision  has  been 
secured  in  the  English  edition  as  in  the  originals.  The  translations  have 
been  edited  by  the  leading  American  specialists  in  the  different  sub- 
jects. The  volumes  are  of  a  uniform  and  convenient  size  (5  x  7^  inches), 
and  are  substantially  bound  in  cloth. 

(For  List  of  Books,  Prices,  etc.  see  next  page.) 

Pamphlet  containing  specimens  of  the  Colored  Plates 
sent  free  on  application. 


VOLUMES   NOW   READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Esrner,  M.D., 
Professor  of  Clinical  Medicine  in  the  Philadelphia  Polyclinic.  With  68 
colored  plates,  64  text-illustrations,  and  259  pages  of  text.  Cloth,  $3.00 
net. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna.  Ed- 
ited by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Depart- 
ment, College  of  Physicians  and  Surgeons,  New  York.  With  120  colored 
figures  on  56  plates  and  193  half-tone  illustrations.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.    By  Dr.  L.  Grun- 

WALD,  of  Munich.  Edited  by  Charles  P.  Grayson,  M.  D.,  Physician- 
in-Charge,  Throat  and  Nose  Department,  Hospital  of  the  University  of 
Pennsylvania.  With  107  colored  figures  on  44  plates,  25  text-Hlustrations, 
and  103  pages  of  text.     Cloth,  ^2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl, 
of  Vienna.  Edited  by  J.  Chalmers  DaCosta,  M.  D.,  Clinical  Professor 
of  Surgery,  Jefferson  Medical  College,  Philadelphia.  With  24  colored 
plates,  217  illustrations,  and  395  pages  of  text.     Cloth,  ^3.00  net. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.    By 

Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs, 
M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hos- 
pital Medical  College,  Nevi'  York.  With  71  colored  plates,  66  text-illus- 
trations, and  122  pages  of  text.     Cloth,  $3.50  net.     . 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye.    By  Dr.  0. 

Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of 
Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  76  colored 
illustrations  on  40  plates  and  228  pages  of  text.     Cloth,  ^3.00  net. 

Atlas  and  Epitome  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek, 
of  Vienna.  Edited  by  Henry  W.  Stelwagon,  M.  D,,  Clinical  Professor 
of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  With  63  colored 
plates,  39  illustrations,  and  200  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology.    By  Dr.  H. 

DuRCK,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.  D.,  Professor  of 
Pathology,  Rush  Medical  College,  Chicago.  Two  volumes,  with  about 
120  colored  plates,  numerous  text-illustrations,  and  copious  text. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.    By  Dr.  Ed. 

Golebiewski,  of  Berlin.  Translated  and  edited  with  additions  by  Pearce 
Bailey,  M.  D.,  Attending  Physician  to  the  Department  of  Corrections  and 
to  the  Almshouse  and  Incurable  Hospital,  New  York.  With  40  colored 
plates,  143  text-illustrations,  and  600  pages  of  text. 

IN   PREPARATION. 
Atlas  of  General  Pathological  Histology.  Atlas  of  Operative  Gynecology. 

Atlas  of  Orthopedic  Surgery.  Atlas  of  Psychiatry. 

Atlas  of  General  Surgery.  Atlas  of  Diseases  of  the  Ear. 


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